proceedings of the - bnmt nepal of national hrh... · message from organizing committee ... role of...

1

National Conference on Human Resources for Health, June 14-15 2013

Proceedings of the

i


ii


MESSAGE FROM ORGANIZING COMMITTEE

iii


MESSAGE FROM TECHNICAL COMMITTEE

iv


TABLE OF CONTENTS

Message from Secretary .......................................................................... Error! Bookmark not defined.

Message from Organizing Committee .................................................................................................... ii

Message from Technical Committee ..................................................................................................... iii

Table of Contents ................................................................................................................................... iv

Acronyms .............................................................................................................................................. vii

Introduction ............................................................................................................................................ 1

OBJECTIVES OF CONFERENCE ............................................................................................................. 1

THEME AND SUB‐THEMES .................................................................................................................. 2

PARTICIPATION ................................................................................................................................... 2

Inauguration Session ............................................................................................................................... 3

Scientific Sessions ................................................................................................................................... 5

PLENARY SESSION: I ............................................................................................................................ 5

Community Based Health Workers: Policy Perspectives in Nepal: Dr Rita Thapa .......................... 5

HRH Planning and HRH Management Approaches with Global and National Outlook: Dr. Wilma

Meeus ............................................................................................................................................. 6

HRH Strategy and Workforce Planning in Nepal: Kedar Bahadur Adhikari .................................... 8

Overview of health sector reform in Nepal: Dr. Baburam Marasini ............................................... 9

Sharing of Findings of Regional Workshop of HRH: Dr. Aruna Uprety ......................................... 10

Deployment and Retention: Quality performance: After Production Side: Dr. Mark Zimmerman

...................................................................................................................................................... 11

PLENARY SESSION: II ......................................................................................................................... 12

Aligning HRH and National Health System: Challenges and Opportunities: Prof. Dr. Arjun Karki 12

Role of Private Sector in HRH Production: Prof. Dr. Hemang Dixit ............................................... 12

PANEL DISCUSSIONS ......................................................................................................................... 14

Investing in Human Resource for Quality Health Services in Nepal ............................................. 14

Conference Recommendations ............................................................................................................ 19

Abstracts ............................................................................................................................................... 21

THEME: HRH STATUS IN NEPAL ........................................................................................................ 21

Human Resources for Health Production in Nepal ....................................................................... 21

Human Resources for Health in Nepal: A National Situational Analysis ....................................... 23

Situational Analysis of Human Resource for Health in Public and Private Sectors in Nepal ........ 24

National Status of Health Workforce in Nepal ............................................................................. 25

v


Human Resources for Health in Ayurveda Sector in Nepal .......................................................... 26

THEME: DISTRIBUTION AND SKILL MIX IN NEPAL ............................................................................. 27

Distribution and Skill Mix of Human Resources for Health in Nepal ............................................ 27

Optometrists as Human Resource for Health in Nepal ................................................................. 28

Integration of Pharmaceutical Care in Health Services: Policy Review ........................................ 29

Access to doctor: TB Services in Far Western Development Region (FWDR) ............................... 30

Success Stories of HRH Pilot Project in Lalitpur District: Case Study ............................................ 31

THEME: DEPLOYMENT, PLACEMENT AND RETENTION OF HRH ....................................................... 33

Responding to Increased Demand for Institutional Childbirths at Referral Hospitals in Nepal:

Implications for Human Resources ............................................................................................... 33

Predictors for the Choice of Future Practice Location among Graduating Medical Students:

Perspective from Social Cognitive Career Theory in Nepal .......................................................... 34

Nursing Human Resources on Present Situation and Its Attractions and Operation at Standard

Guideline of Nursing Workforce ................................................................................................... 35

Training, Recruitment, Placement and Retention of Health Workforce in Nepal ........................ 36

THEME: CAREER DEVELOPMENT, EDUCATION AND TRAINING FOR HRH ........................................ 38

Career intentions of medical students in Nepal ........................................................................... 38

Beyond Training – The Follow‐up Enhancement Program ........................................................... 39

Human Resources for Health: Career Development Perspectives ............................................... 40

Medical Students’ Characteristics as Predictors of Career Practice Location: Retrospective

Cohort Study Tracking Graduates of Nepal’s First Medical College ............................................. 41

THEME: MOTIVATION, PERFORMANCE AND ACCOUNTABILITY OF HEALTH WORKERS .................. 43

Motivation and Retention of Health Workers in Nepal ................................................................ 43

Health Workforce Performance and Accountability ..................................................................... 44

Working Conditions of Health Workforce in Nepal ...................................................................... 45

Job Satisfaction of Health Workers Working at Peripheral Health Institutions in Siraha District 46

Patient Satisfaction with Nursing Care in Different Hospitals of Kathmandu Valley .................... 47

THEME: HRH POLICY AND MANAGEMENT ....................................................................................... 49

HRH Gap Analysis in Relation to National Objectives and Priorities ............................................ 49

Human Resources for Health (HRH) Management from Central to District Level in Nepal ......... 50

Health Governance at Local Level from Human Resource for Health Perspectives: The Case of

Nepal ............................................................................................................................................. 52

Human Resource for Health in Nepal: Analysis of Policies and Practices ..................................... 53

Human Resource for Health: Views of Public Service Commission .............................................. 54

THEME: ROLE OF PRIVATE SECTOR INCLUDING PUBLIC PRIVATE PARTNERSHIP FOR HRH ............. 57

vi


Role of Civil Society in Human Resources for Health Management in Nepal ............................... 57

Public Private Mix Collaboration Model in Enhancing Tuberculosis Case Detection: An

Experiences from Eastern Nepal ................................................................................................... 58

Perception of Government Knowledge and Control over Contributions of Aid Organizations and

INGOs to Health in Nepal: A Qualitative Study ............................................................................. 59

Activation of HFOMC for HRH Management: Impact of HRH Pilot Project .................................. 60

THEME: GLOBALIZATION AND MIGRATION OF HEALTH WORKERS ................................................. 62

Brain Drain of the Health Work Force: A Global Problem ............................................................ 62

Involving Diaspora as Human Resources in the Health Sector in Nepal ....................................... 63

Causes, Consequences and Remedies of Migration of Human Resources for Health (HRH) from

Developing Nations in the Globalized World ................................................................................ 64

Effectiveness of Human Resources for Health Pilot Project in Kharkada Sub‐Health Post .......... 65

THEME: MEDIA COVERAGE FOR HUMAN RESOURCES FOR HEALTH ISSUES .................................... 67

Human Resource for Health in Nepali Print Media ...................................................................... 67

HRH Coverage in Broadsheet National Dailies: A Content Analysis ............................................. 68

Mass Media's Role in Ensuring Human Resources for Health ...................................................... 69

OPEN PAPERS .................................................................................................................................... 71

Human Resources — Accounting and Auditing ....................................................................... 71

Users Perspectives on Barriers to Receive Reproductive Health Services in Selected Public

Hospitals of Nepal ......................................................................................................................... 72

Reactivation of HFOMC for HRH Management at Baneshwor HP: A Success .............................. 73

Annexe ..................................................................................................................................................... i

ANNEXE 1: COMMITTEES FOR CONFERENCE ....................................................................................... I

ANNEX 2: PROGRAM SCHEDULE ......................................................................................................... II

ANNEX 3: LIST OF PARTICIPANTS ...................................................................................................... VII

vii


ACRONYMS

AHW Auxiliary Health Workers

ANM Auxiliary Nurse Midwife

BDS Bachelor in Dental Surgery

BPH Bachelors' in Public Health

BPKIHS HP Koirala Institute of Health Sciences

CB-HRH Community Based Human Resources for Health

CDs Communicable Diseases

CMAs Community Medical Assistants

CSO/NSAs Civil Society Organizations/Non State Actors

CTEVT Council for Technical Education and Vocational Training

DDCs District Development Committee

DHO District Health Office

DPHO District Public Health Office

DRC Development Resource Centre

EDPs External Donor Partners

EU European Union

FCHVs Female Community Health Volunteers

FGDs Focused Group Discussions

HA Health Assistant

HFOMC Health Facility Operation and Management Committee

HR Human Resources

HRH Human Resources for Health

HuRIS Human Resource Information System

HW Health Workers

I/NGO International Non-Government Organizations

IOM Institute of Medicine

KU Kathmandu University

MBBS Bachelors in Medicine and Bachelor in Surgery

MCHW Maternal and Child Health Workers

MDGPs MD General Practice

MDGs Millennium Development Goals

MDR TB Multi Drug Resistance Tuberculosis

MN Masters of Nursing

MOGA Ministry of General Administration

MoHP Ministry of Helath and Education

MPH Masters of Public Health

viii


MS Master of Surgery

NAMS National Academy of Medical Sciences

NCDs Non-Communicable Diseases

NCDs Non Communicable Diseases

NEPHA Nepal Public Health Association

NGO Non Government Sector

NHRC Nepal Health Research Councils

NHSP Nepal Health Sector Plan

NHTC National Health Training Centre

NMC Nepal Medical Council

NNC Nepal Nursing Council

NPC National Planning Commission

NSI Nick Simons Institute

OJT On-the-job-training

PHC Primary Health Care

PPH post partum hemorrhage

PPP Public Private Partnership

PSC Public Service Commission

SBAs Skilled Birth Attendants

SHP Sub Health Post

SWAP Sector Wide Approach Programme

SWC Social Welfare Council

TBAs Traditional Birth Attendants

TM Traditional Medicine

TU Tribhuvan University

TUTH Tribhuvan University Teaching Hospital

UHC Universal Health Coverage

VDC Village Development Committee

VHW Village Health Workers

WHO World Health Organization

WISN Workload Indicators of Staffing Needs

1


INTRODUCTION

Meeting the Millennium Development Goals (MDGs) related to population health is crucial. Government of Nepal has spelt out that health is a fundamental human right of every citizen and is trying its best to achieve the targets of the MDGs. Three out of eight goals, eight of the 18 targets and 18 of the 48 indicators relate directly to health. Health is also an important contributor to several other goals. In health sector, some countries have performed quite well and achieved the targets but still some countries have not. . In this regard, Nepal has achieved significantly but still a lot of improvement is essential to ensure healthy life of Nepalese population.

Human resource is one of the vital ingredients of the health system. No country can achieve the health related MDGs and universal access without a competent, motivated, supported and equitably distributed health workforce. To achieve the goal of National Health Policy and ensure effective management of the national health system human resource plays a vital role. The National Conference on Human Resources for Health (HRH) held in Kathmandu on 14-15 June, 2013 was conducted to assess the current status and explore the inherent challenges in the field of HRH in Nepal which will guide policy makers and planners to envision the HRH strategies effectively.

This national conference on HRH uniquely brought together all the key stakeholders:- the government, international agencies, academic institutions, health care professional associations, civil society, foundations and other non-state actors to achieve to deliberate over ‘Investing in Human resources for Quality Health Services in Nepal’ which was the theme of the conference.

Nepal faces triple burden of diseases constituting communicable diseases, non-communicable diseases including malnutrition and accidents/injuries on top of coping with the shortage of health workforce. There is a need of immediate action to resolve the shortage and unmatched distribution of health workforce helping to ensure access to quality health care and improved health outcomes. All Nepalese deserve access to skilled, motivated and well-facilitated health workers within the national health care system. The spectrum of HRH constituting the essential continuum of planning, training, deployment and retention needs to be well structured.

OBJECTIVES OF CONFERENCE The conference was conducted to assess the existing scenario of human resources in the country by sharing thoughts, experiences and practices in the field of HRH and offer practical recommendations for the way forward and to enhance commitments to investment in HRH.

The specific objectives of the conference were:

to share global and national perspectives on on HRH policy, planning and HRH management

to provide comprehensive picture of HRH status in Nepal to explore the scenario of distribution and skill-mix of HRH in Nepal to undertake the review and analysis of the deployment, placement and retention of

HRH to explore the career development (education/training) for HRH to understand the motivating factors for HRH

2


to explore the public private partnership in HRH to discuss the impact of globalization and migration of health workers from Nepal

THEME AND SUB-THEMES

The main theme of the conference is Investing in Human Resources for Quality Health Services in Nepal

The sub-themes are as below:

HRH Status in Nepal HRH Distribution and Skill-mix in

Nepal, Deployment, Placement and

Retention of HRH HRH Production, Trainings and

Capacity Building Opportunities Working Conditions and

Motivation of Health Workers HRH Policy, Plan and Management Role of Private Sector, including

Public-private Partnership for HRH, Media and HRH, and Globalization and Migration of

HRH.

PARTICIPATION A total of forty eight papers along with few key notes were presented during two days conference with the participation of three hundred sixty three (363) participants from different sectors and different levels. Looking at the sector-wise participation, civil society organizations/non state actors (CSO/NSA) participants were in the highest number followed by participants from the government sector from different levels: district/public health office, regional health office and central level. More than three- fourth of the participants were males. There was a higher numbers of female participants from external donor partners (EDPs) including international non-government organizations (I/NGO), CSO/NSAs and others from academic institutions (Table 1). For details, please see annexe 3.

Table 1. Participation in conference from different sectors

Institutions Male (%) Female (%) Total

Government 90 (24.8) 7 (1.9) 97 (26.72)

EDPs 55 (15.2) 28 (7.7) 83 (22.87)

CSO/NSAs 78 (21.5) 21 (5.8) 99 (27.27)

Other 11(3.0) 20 (5.5) 31 (8.54) Academic Institutions 26 (7.2) 3 (0.8) 29 (7.99)

Media Person

19 (5.2) 5 (1.4)

24 (6.61)

Total 279 (76.9) 84 (23.1) 363 (100)

3


INAUGURATION SESSION

The conference opens with the inauguration session. The chief guest Hon. Minister, Vidyadhar Mallik, Ministry of Health and Population inaugurates the conference. Secretary, Ministry of Health and Population, Dr. Praveen Mishra chairs the opening session of the conference.

Joint Secretary at the MoHP Kedar Bdr. Adhikari, the chairperson of the Conference Organizing Committee welcomes the participants of the National Conference on Human Resources for Health (HRH) by setting forth the purpose of the conference. He says Nepal is facing shortage of HRH according to WHO. In addition to that there is a problem of retention of health workers at rural health institutions. One of the factors contributing to the problem is low financing in HRH. Meanwhile, productivity of the existing health workers is also limited and inadequate skill mix is prevalent. Health workers lack updated knowledge and skills. The expert team at the Ministry of Health and Population is working hard to address the needs of HRH. He emphasizes that the present conference will come up with practical solutions to address the HRH issues in Nepal.

His speech is followed by a documentary show that depicts that depicts the existing problems in HRH in Nepal. A case study of the far west is presented. It reflects the practical issues related to HRH: A mother dies due to post partum hemorrhage (PPH) after delivery of twins. She is not attended by doctors and the health institutions lack the service to address her healthcare need. She was a teacher of the primary school in the village. HRH situation of Doti, Siraha and Bardiya districts is captured in the documentary. The documentary reveals that health centers have been the victim of political and other pressures and lack of security and opportunities are the main reasons for low retention of HRH in the districts and the periphery. As per WHO, there must be 23 health workers per 10,000 but in Nepal there are 7 health workers per 10,000 population.

In his opening remarks, Dr. Mingmar Gyaljong Sherpa, Director General of the Department of Health Services states that it is essential to update the HRH document. He opines even during the time of Maoist insurgency in the country, the health workers (HWS) have tried their best to improve the health status of people. Thus Nepal has achieved the targets of MDGs. MoHP is depending on different cadres of health workforce of the country including female community health volunteers (FCHVs), traditional birth attendants (TBAs), auxiliary health workers (AHWs) and village health workers (VHW) to improve the health of the people. He further emphasizes that more staff are needed to address the health needs of the community in recent days due to state policies. The newly recruited doctors are sent to the remote areas who are finding difficulty in catering to the health care needs of the

4


people. We need to emphasize the skill components of the newly produced doctors and health workers besides knowledge.

Dr. Alexander Spachis, Ambassadors of EU delivers a remark on EU’s effort and commitment on supporting HRH sector in Nepal. He states that low level of retention and utilization of Health Workers and unequal distribution are the major hindering factors. Lack of opportunities causes the problems of brain drain. This calls forthe need for coming up with incentive schemes for health workers. Nepal needs strong support in this sector and expresses that other international partners are ready to support Nepal in HRH. He believes that the present conference is a platform to share the experiences in HRH in Nepal and will be fruitful.

The chief guest of the opening session Minister for Health and Population Mr Bidhyadhar Malik outlines that poor incentives are hindering the retention of health workers at the periphery and expressed that the government is serious about the problem and trying its best to address it. He expresses his firm commitments to ensure transparency in the health sector and highlights the essence of supervision and monitoring to strengthen the programs. He believes that the present conference will offer practical recommendation to address HRH issues. Meanwhile he highlights that the role of the private sector, I/NGOs and civil society is equally important to address the issues in HRH. He assures his commitments to increase the budget in the HRH sector.

In his closing remarks of the inauguration session, Dr Praveen Mishra, Secretary to Ministry of Health and Population expressed the need to provide quality health services up to the grassroots level. Ironically, there is discrepancy in population increment and HRH production and induction into the health sector service, causing disparity in addressing the health needs. His key message is Health should be incorporated into all the developmental agendas. According Dr. Mishra this contributes to sustainable development of the country and betterment of life of people. HRH should be managed properly- addressing the retention, absenteeism and other issues in HRH. He outlined that the government has created an environment for health workers and also arranged for incentives. He believes that upgrading the health institution will help to increase the number and quality of HWs. There should be coordination among Government, I/NGOs and other sectors to ensure that health services are available in rural areas. He expects that the conference will help to produce recommendation to address HRH issues that fit with the country reality.

National Con

PLENAThe firstco-chaireWilma MDr. Mark

Commu

Dr ThaDevelopmin Nepalthe backNepal scommundeliveringMalaria Putilized tEradicatiothrough 1970s InDevelopmspecializerepreseninternatiogave imphuman reCB-HRHbig challconstrainis facing. regular first levethrough educationlogistics for strecenters, There isFCHVs health sytransitionhealth ca

Meanwhicommodskilled Hcountry. sustain o

ference on Hum

RY SESSIOt plenary sesed by Dr. SMeeus, Mr. Kk Zimmerma

unity Based

apa presentment of Hul: A Commkground of since 1957ity-based mg health carProgram wathe communon of small community-

ntegrated Coment (ICHSed HRH, acnted HRH atonal arena, Aortance to cesources fo

H can do onlyenge. Negle

nts that our Maintainingback up sul health syst

continuen (CME) ansupport. Thengthening

trainers, ms the threatfrom the ystem. This n might comare performa

ile World Hdities should RH in rural Dr. Thapa f

our health. L

man Resources fo

ON: I ssions “key Sushil ChandKedar Bahadan.

d Health W

ted the pman Resour

munity-based the health7, she hig

model has bere in Nepalas initiated inity people i pox projec-based vaccommunity HSD) programccordingly ht the top twoAlma Ata Dcommunity-r health (CBy so much. Aected mate health syste

g CB-HRH aupport of ttem is possibed medind the needhere is a ne

the trainimaterials, et of delinkifirst level long politimpromise tance.

ealth Assem be made ac areas. Matefurther highikewise ther

or Health, June

SCIENTIF

note presendra Baral. Pdur Adhikar

Workers: P

paper entitrces for He Model. Givh programsghlighted heen adopted. During 19in Nepal whn the progrct was possinators. DuHealth Servm involved Vhealth staff o levels in theclaration abased HRH.B-HRH) is iAcute lack o

ernity & neem and the ble cal

dful eed ing

etc. ing of

cal the

mbly 66/69 dccessible to ernal and nehlighted that re is the ess

14-15

FIC SESSIO

ntation” wasPapers werei, Dr. Babur

Policy Persp

led- alth ving of

how d in 960s hich ram. sible ring ices VHWs, FCHwere sent he pyramid

and later Mil. The contrmpressive in

of skilled HReonatal heal

emands thateach wome

eonatal healt there is thesence of cap

ONS

s chaired bye presented ram Marasin

pectives in

HVs. Nepal abroad for shown in figlennium dev

ribution of Nn making gia

RH at remotth care se

t 9 essential n of each coth care serve need of inacity buildin

201

y Dr. Chet R by Dr. Rit

ni, Dr. Arun

Nepal: Dr

realized th higher edugure 1. Meavelopment GNepal’s Comant strides ite and rural rvices are

life saving hountry. Thervices are negnter-sectorag of HRH at

13

Raj Panta anta Thapa, Da Uprety an

r Rita Thap

he essence oucation whicnwhile, in th

Goals (MDGmmunity-base

in health. Buareas posesother majo

ealth servicere is a lack oglected in thl approach tt all levels fo

5

nd Dr. nd

pa

of ch he s)

ed ut a or

es of he to or

6


advocating and implementing health in all the development policies. To acquire the vision and mission of our health system, there is the need to build conducive environment for recruiting health workers from the community itself and ensuring HRH career ladder and incentives.

HRH Planning and HRH Management Approaches with Global and National Outlook: Dr. Wilma Meeus

Dr Wilma highlighted that there has been changes in the patterns of diseases, thus the training of human resources for health needs to address these new health problems. Urbanization is in the increasing trend and rural area is shrinking. This leads to change in the morbidity pattern and the demand for health services. Utilization is higher in urban areas than in rural areas mainly due to financial and geographical reason and also due to the availability of the services. The link between the MDGs and the health workforce has been proven. Similarly, there is a need to ensure that there is interconnectedness between HRH and universal health coverage (UHC).

1. Health workforce planning

Nepalese data show that there has been an increase in chronic diseases and diseases caused by increase in traffic and pollution. Urbanisation rate is very important for a number of reasons. In some countries urbanisation has increased rapidly because of out-migration of younger people from traditional income earning activities (farming, cattle rearing, etc). However, because of poor employment opportunities, many urban dwellers are now marginalised as they also lose their subsistence income. Big slums / townships are known for the usual morbidity pattern as well as mental health issues, substance abuse, etc. Urbanisation also offers opportunities because people live closer to health facilities: more rational use of health workers by changes in the organisation of services. In Zambia, the introduction of differences between staff establishments of urban and rural clinics worked well, especially also because the population was consulted about the best days and times for preventive activities, and were better informed about service availability in the afternoons. This has meant that staff on duty in the afternoon continues with ordinary curative (and preventive) services, which previously was only done in the morning.

Dr Wilma mentioned that the questions in HRH planning process are:

How much is needed to hire more personnel, to pay more to existing personnel or do both?

Where will the money come from (taxpayers, other sectors, savings, and external sources)?

What will be the impact on other sectors of spending more on health, i.e. will paying health workers better have a spilling effect, and how much will that represent?

7


Workforce projections can be defined as estimates of what will happen in the future using calculations based on assumptions. Workforce requirements can be defined as the numbers and types of staff needed (in relation to demand or needs).

Workforce / population ratio is inaccurate, based on assumptions of utilisation of health services and not proportioned according to population density, need for team work and possibility of isolation of health workers, etc.

Service demand method draws on utilisation rates for different population groups, applies these rates to the future population profile to determine the scope and nature of expected demands for services, and converts these into required health personnel by means of established productivity norms (work load).

On productivity standards, some selected methods and tools that have been used in the context of workforce planning and projections, and to support decision making for policies and programmes include the workload indicators of staffing needs (WISN) methodology. This is a tool developed and field-tested by WHO for setting activity (time) standards for health personnel and translating these into workloads as a rational method of setting staffing levels in health facilities (WHO, 1998).

The following are the measures to address urban-rural health worker imbalances:

Allocating more budget funds in order to create additional health worker positions, especially in rural areas (that is, increasing HRH demand)

Increasing capacity for training more health workers Forcing health workers to work in rural areas (using compulsory community service

or bonding) Providing financial incentives for health workers accepting work in rural areas

Planning for international migration:

A major difficulty in accurately projecting and planning the workforce is related to the unpredictable loss of skilled staff members to private health sector jobs, jobs abroad, and jobs outside health.

Internationally recognized cadre:

Workforce / population ratio usually only includes qualified health professionals in its calculations.

Many countries with health workforce shortages have introduced new cadres to address existing gaps, e.g. Clinical Officers / Medical Assistants, Nursing Aids / Assistants / Auxiliary Nurses, Microscopists, etc. who can provide specific tasks.

Pressure from Professional Associations not to recognise ‘new’ professions. As these cadres are not included in calculations, ratio appears to be lower.

2. HRH management

Most performance problems can be attributed to unclear expectations, skills deficit, resource or equipment shortages or lack of motivation.

Apart from political and socioeconomic environment (contextual factors) HRH performance is determined by:

8


Individual factors - health worker characteristics e.g. security, living conditions, gender, age

Factor at micro (health facility) level, e.g. work conditions, team setting and team work, local monetary and non-monetary incentives (housing…), career prospects and development opportunities

Factors at macro (health system) level, i.e. HR planning processes, deployment and skills mix, local recruitment, remuneration and allowances, community service / bonding

Involving health workers in problem analysis and generation of solutions is extremely important for performance improvement.

Compulsory community service Rural retention schemes Internal and peer supervision Performance based financing Rural retention scheme: monetary incentive / salary top up plus access to loans for

transport, schooling for children, post-graduate training.

HRH Strategy and Workforce Planning in Nepal: Kedar Bahadur Adhikari

Mr Adhikari stressed that HRH is an important issue to address the following problems in Nepal:

‐ meeting MDGs ‐ mal-distribution of HR ‐ poor staff performance ‐ fragmented approach of HR planning ‐ insufficient HRH finance ‐ imbalance between supply and demand

The major challenges in government and private system are: ‐ lack of health workers in rural areas ‐ lack of efficient health workers ‐ study leaves ‐ insufficient training ‐ imbalance distribution of human resources ‐ retention challenges ‐ poor physical infrastructures ‐ need to have benchmark for every health service center ‐ shortage of health workers. Huge difference in the number of Registered health

workers and the number of workers working Goals and output of HRH strategic plan:

‐ support in the implementation of Nepal Health Sector Plan (NHSP) ‐ equitable distribution of appropriate, efficient and skilled HRH

Major Outputs

Output 1: Appropriate supply of health workers for labor market needs

Output 2: Equitable distribution of health workers

9


Output 3: Improved health worker performance

Output 4: Effective and coordinated HR planning, management and development across the health sector

Key assumptions

• MoHP and other top level government agencies remain committed to HR improvements

• Partners make strategic and coordinated efforts in order to address HR issues • Support for implementation and monitoring of the HRH Strategic plan continues

(NHSP II)

HRH strategy implementation

Some of the activities currently underway to implement the HRH Strategic Plan include:

• Analysis of factors affecting the supply side including the numbers and characteristics of HR produced by the existing education system, the nature and dynamics of the labour market, and the roles played by the private health sector and NGOs etc.

• Implementation of post creation of 14, 000 HR workforce to address immediate needs

• HRH assessment of both the public and private sectors • Preparation of a workforce plan up to 2030 • Functional review of MoHP and its subordinate authorities • Further improving Human Resource Information System (HuRIS) • Initiation of a process to fill the positions required within the strategic plan period.

Following factors need to be considered while determining HRH:

• The population will grow annually with some of the population moving from rural to urban areas.

• The financial context will improve with government budgets increasing incrementally per year

• The demand for health care will grow over time and is expected to be high by 2030 • Although infectious diseases are of concern at present, non-communicable diseases

(NCDs) will increasingly become major public health threats by 2030 • The role of the private sector may change in the number and type of services, but is

expected to grow in the next 17 to 20 years.

Overview of health sector reform in Nepal: Dr. Baburam Marasini

Dr Marasani stated that currently the health sector reform is undergoing in 60 countries in the world. There are 3 phases of sector reform program development. Health sector reform policy change, implementation and outcome phase. In the Health sector, there is a broad concept that incorporates both modern and traditional health service providers, regulatory bodies, policy makers, pharmaceuticals, I/NGOs, government organization and other public sectors. There are 3 Es in Health Sector Reform which are Effectiveness, Efficiency (regarding money or value for money) and Equity (narrows down health disparities and achieves equitable distribution). Sector Wide Approach Programme (SWAP) brings together government, donor agencies and stakeholders.

10


NHSP is an umbrella program led by secretary; it is a 5-year national health plan and is a road map towards achieving MDGs and for implementation of the health sector strategy and also financing plan for health sector in a sector wide approach.

Objectives of NHSP are to achieve MDGs, reduction of poverty, reduction of socio-cultural and geographical barriers, increase utilization of health services and reaching underprivileged and marginalized population.

The followings are the achievements of NHSP Near to achieving MDG 4,5,6 4 folds increase in health budget

The challenges to address NHSP are: Political transition HR problems Governance and accountability Capacity development Training of health workers

o Quality of care o Addressing equity issues

In conclusion, there has been improvement in service delivery, suitable human resource for health are critical need and health disparities is in the process of narrowing down.

Sharing of Findings of Regional Workshop of HRH: Dr. Aruna Uprety

Dr Upreti stressed the need for investing in Human Resources for quality health services in Nepal. Many activities have been conducted at district and regional level but due to lack of transparency and reporting to the central level, this has not been recognized at the central level. Problems in districts might be different as per the local context but there is resemblance in basic features. She highlighted the following issues related to health workers:

Most important workers are not afraid to work, but the workers want their voices to be heard and involvement of grass-roots level people in planning (Bottom-up Planning).

Decentralization has been a hot topic but when it came to implementation the scenario is not encouraging.

Retention: Salary benefits, minimum benefit should be appropriately provided to the HWs. They are willing to work.

Policy and strategy: Karnali example: Geographic hindrances leads to lack of security of health workers, political reasons (community people and local leaders)

Monitoring and evaluation: o Is not done properly. No system of rewarding the people who fulfil their

duties properly. o There is a post of monitoring and evaluation officer but no one is there to

perform such activity. o Monitoring and evaluation should be done objectively and subjectively and

the results should be incorporated in the future planning and implementation. Behaviour modification in between doctors and patients relationship. Resource allocation and mobilization

o Distribution of poor quality medicine and equipment to rural poor people as there is provision of issuing tender to get the cheapest equipment and drugs.

11


Deployment and Retention: Quality performance: After Production Side: Dr. Mark Zimmerman

The performance of health system depends on the health workers. There should be coordination between all the sectors. Poor distribution of health care workers causes overcrowding of referral to central level and underutilization of health services. A documentary was shown, that showed that there has been utilization of the health services after expert doctors were assigned to the hospital (Doti). People were satisfied with the services provided in the hospital. The following are the strongest measures to address HRH problems: task shifting, garnering local support, retention and attraction, retention and enhancement of performance of health care workers. Nick Simons Institute did intervention in three districts as part of Rural Service Support Program. As per the experience of RSSP: 7Cs can support retention of Family Physicians at the districts: Continuous quality improvement, clinical coordination by MDGP Doctor, continuing medical education, connection with district, comfortable quarters, capital items, communication and community governance. The results of the rural support programme showed: the higher the retention of doctors at district level with better the health care utilization. Chair: Dr Chet Raj Pant, the chair of the session, stressed that the common problem in Nepal are: rural-urban disparity, scholarship issues and how to project the future of health workforce. Stability is needed in MoHP as well and there should be coordination among various sectors to address the HRH issues. Inter-sectoral approach is needed. Salary incentives should be provided to health workers who work in the rural areas. Very few doctors are practicing in rural areas but we have produced thousands of doctors each year. There is an imbalance between demand and supply. There also exists a mismatch between rural and urban, government and private sectors and education and health service. Co-chair: Dr Baral highlighted that post MDG (universal Health coverage) cannot be achieved without addressing HR. There has to been a holistic approach for HR. Many activities need to be done to address HR issues. Health system is not only government but also private and NGO led (local innovation needs to be done).

12


PLENARY SESSION: II The session was chaired by Dr Rita Thapa and co-chaired by Dr Ram Prasad Shrestha. The paper was presented by Prof Arjun Karki and Prof Hemang Dixit.

Aligning HRH and National Health System: Challenges and Opportunities: Prof. Dr. Arjun Karki

Health is the foundation of New Nepal. The interim constitution of Nepal, 2063 has recognized the right of people to live in a healthy environment. HRH is the cornerstone of health services. National Health Policy - 1991 has aimed to extend PHC to rural population so that the benefits are taken from modern medical facilities as well as issues of HRH are addressed. Second Long Term Health Plan also wants to reach out to the poor and underprivileged and provide appropriate medical sources. NHSP II recognized the importance of competent and motivated health workforce. The density of health workers is directly proportional to the life expectancy and quality of life of people. Distance of health facilities is also related to accessibility of health services by people. Major health issues:

Triple burden of diseases (CDs, malnutrition, NCDs, and injuries), Poverty, topography, Political instability and ineffective health service.

Governance, accessibility, communication, finance, HRH all are necessary for the delivery of health services and people must be the core of health. Holistic concept must be adopted in the health system. System failure requires system solution. The health of people is not only determined by the health system alone so it should be viewed as a broad concept. The disparity in rural-urban population can be bridged by innovative medical education, in-service support (deployment, retention, incentives, infrastructures etc), rectification of system, Telemedicine in Nepal is available in limited districts but should not be limited and extended to all districts and sub-districts. Improvement in the conditions of daily life and tackling the inequitable distribution are needed. Social support is the foundation of production and utilization of the HRH so medical schools should increase the social accountability and reach to every people. Paramedics, FCHVs, peace, social justice are must

Role of Private Sector in HRH Production: Prof. Dr. Hemang Dixit

Medical schools started in Nepal from 1934. Since 1952-1972 HRH production was done by MoHP only. It was only after 1990 that the private sector started production of HRH. Currently, about 80% production is done by the private sector. The statistics are still not reliable in this connection. Records of HRH are not well maintained or consistent. There are no provisions of training of human resources and their

13


supervision and monitoring is still a burning issue in the country. 2,000 doctors are being produced every year but still there is lack of HRH due to the problems of deployment and policies. Pharmacists are also important aspects of health system in our country. Skill mix and team of health professionals are required. Talking about dentist, out of the total dental surgeons 507 are males and remaining the 715 are females. HRH utilization is done by government institutions, private institutions and medical institutions abroad too. Posts are not created with the increase in population - there is a problem of deployment. Anticipated problems and recommendations are:

‐ There is problem of a large number of intake in all categories. To improve, On-the-job-training (OJT) and internships must be compulsory in all discipline.

‐ Supervision, absenteeism and dissatisfaction with the health care services are prevalent, which in some cases leading to violence against health care providers. Positive gains- practicing on their own and women empowerment Negative gains- no updating of information, no reliable statistics

Chair

HRH is an old issue The knowledge and skills of health workforce must be utilized by coming

together Ministry, HRH producing institutions and local people must coordinate Local sentiments and needs must be addressed by the health system The essence of federal government is to reach out to the people and in villages

through coordination with institutions, CSOs and local bodies Co-Chair

Quality and quantity of production and retention of manpower is a concern We can take a couple of districts to administer pilot projects by bringing multiple stakeholders together and let the districts be role models and extend the programme if found effective

14


PANEL DISCUSSIONS

Investing in Human Resource for Quality Health Services in Nepal

Chair Dr. Tirtha Rana Panel Member: Dr. Baburam Marasini (Representative of MoHP), Prof. Dr. Jagadish Agrawal (Medical Education Department, IOM, representing for professional level of HRH), Prof. Dr. Arjun Karki (Senior Faculty Member, Patan Academy of Health Science, representing for paraprofessional level of HRH), Dr. Damodar Prasad Gajurel (Chief Nepal Medical Council, representing for Quality Assurance of Medcial professional HRH), Dayalaxmi Baidya Joshi (Chief Nepal Nursing Council, representing for Quality Assurance of HRH, nursing), Dr. Muktiram Shrestha (Nepal Medical Association, representing for safety and security of Medical HRH), Ram Bhandari (Nepal Public Health Professional Association, representing for Safety and security and quality of Public Health professionals) , Dr. Khem Karki (Coordinator of CSO NSA HRH Allaince, representing NSA/CSOs). The objectives of the discussion was the status of HRH; existing HRH plans and policies; quality of HRH Production and supply, safety and security of HRH; prevailing management issues; problems, challenges and opportunities of HRH; monitoring, standardization, ethics and accreditation of HRH; way forward to address HRH issues to provide quality health care and universal health coverage. 1. Dr. Babu Ram Marasini representing Ministry of Health and Population Modern health service began in Nepal with the establishment of Bir Hospital in 1945. During Rana regime, two schools Rajakiye Bidhyalaya and Civil Medical School were established. Following this, other public institutions sprung up until 1990 AD. The public sector used to produce HRH as per demand but it created a mismatch between demand and supply. After 1990, new elected government adopted the liberal economic policy and the process of the establishment of private medical colleges was initiated. At present, there are 6 public, 12 private medical colleges (80% doctors produced are from the private sector). Government took liberal approach leading to operation of private institutions. NHSP strategic document has forecast the quantity of HRH by 2017 but was mainly focused on the public sector. The government is the largest employer. After the government, local development bodies have been hiring staff. Quality and competency of medical doctors is the big concern and there is a decrease in the willingness to serve in public sector among the health service providers. Quality HRH would contribute to the delivery of quality health services so focus should be on quality rather than quantity from the stage of teaching and training. The trend of creating jobs at local level is on the rise. However, the quality is in question. There are doctors who still lack skills to perform minor operations, vasectomy or child delivery in many rural parts of the country. In remote areas, the weakness doesn’t only lie in the doctor’s part; there are also a low number of staff nurses and other paramedics to support the doctors. Quality

15


should be our major concern. So, both the qualitative and quantitative issues should be addressed with top priority in HRH sector as national agenda. 2. Prof. Dr. Jagadish Prasad Agrawal representing Medical Education, IOM Institute of Medicine (IOM) was the first and foremost medical school in Nepal which was established in 1972. MBBS program was started in 1978 at IOM and considered as one of the innovative medical schools of the world. The founder doctors focused on quality rather than quantity. In 1978, it started a suitable programme for Nepal. Post graduate programme was started in 1984. IOM is producing both specialist and super specialists, aiming to produce 100 specialists annually. Initially IOM focused on community based education and established infrastructure for the purpose. But lately it was deviated. We intend to go back again to the community focused programme. IOM has revised the ethics and community issues and developed new curriculum as per the need of the country. The common mentality is that IOM produced graduates migrate, but the study of NSI, shows that 66% of the IOM graduates work in Nepal. Our challenge is the medical schools of Nepal especially the private institutions should improve innovations needed for the 21st century education. Selection criteria should be based on merit. In fact, shortage is not that serious but we are fragmented, we are not socially accountable. So there is a need to work together with health authority and institutions to address this concern. 3. Prof. Dr. Arjun Karki, representing for paraprofessional level of HRH Till 1990, 80-90% of services were provided by doctors of IOM. The change in the criteria of selection in the institution also proved to be one of the setbacks. Paramedics must be acknowledged and given opportunity for skill development and at least sit in the exams of undergraduate medical courses. Supply and incentives is the issue of everyone working in the health sector. The future of paramedics is uncertain. In 1978, our MBBS program started. Only in-service staffs of IOM were allowed to join. If the records of Ministry are intact, we find, 80% of doctors produced from IOM are serving far-flung locations. Recently, a report came out on absence of doctors in emergency service in Bir Hospital. There was a culture of ANM, Nurse to go for MBBS, lately even the Ayurved and paramedics were allowed to join. The process was withdrawn citing India is not recognizing it. Still, in rural areas, 80-90 percent paramedics are available. To realize the provision of the constitution that everyone be guaranteed with health service paramedics should be credited. The motivation, supply and supervision to facilitate and motivate them has to be given due attention. It’s often heard that CTEVT produced paramedics are of low quality, but, if this is there, let them face the entrance rather than criticizing the trend. The state is not providing them with necessary support to encourage them to continue with their services. IOM is the pioneer institution to enrol paramedics. NSI and IOM data shows where the doctors produced from 21 batches are stationed. So, if they have the capability they should be allowed to join medical service. Patan Academy of Health Sciences has prioritized the certificate level health workers in MBBS if they are willing to work in rural areas which must be adopted by IOM and BPKIHS as well. 4. Dr. Damodar Prasad Gajurel, representing for Quality Assurance of Medical

professional HRH Medical Council was established by the government to ensure the quality of medical workforce produced by home and outside institutions. So our major objective is to ensure quality. Quality is not only the degree, knowledge but also the person's attitude which is also a core determinant of quality. The council should identify who is eligible to be a doctor, not only on knowledge but also based on attitude, which only can give quality in health

16


service. People in Jumla now do not need experts, but someone who can treat basic problems. Currently private colleges produce around 1, 800 doctors while government produces 235 only. I believe private institutions should not dominate production. It is unfortunate that the government institutions are unable to cope with the demand. It’s a shame that Nepal meets only 0.5 doctors per 1000 people while the OEDC requirement is 3.1 per 1000 people. WHO standard requires 23 doctors per 10,000, but Nepal only has 7. IOM has more than two dozen faculty members in a department but produces only 61 doctors. The faculty doesn't want to produce more doctors. Dharan institute has billions of rupees investment but only produces 100 doctors. However, the private Nobel Medical College produces 150 students. We are unable to change skill and attitude, beside knowledge. If we evaluate knowledge and quality, the license exam showed out of 57 from Nobel passed. With huge investment, the same result came for Dharan. Holistic approach should be taken to know about knowledge, quality. The problem is private colleges are not finding teachers. Private colleges are profit making institutions, so given our state mechanism and mentality; it is really challenging to maintain the quality. NMC has also started the license exams for those doctors. From this year, medical ethics, communication skills and updating of knowledge and skills is made mandatory for medical doctors. 5. Dayalaxmi Joshi Baidhya, representing for Quality Assurance of HRH,

nursing Medical Council and Nursing Council are both facing similar challenges. Profit making is the focus for people who open nursing colleges. There is no coordination between the Ministry of Health and Population and the Ministry of Education: while one is liberal the other wants total control The council has been conducting monitoring, accreditation every 5 years and the license exam since 2011 to maintain quality. Strengthening governance and skill mix is necessary. Plans and policies must be made relevant to the country as per demand and needs. Nursing council has neither the right to open nor the right to close an institution; it provides counselling, monitoring, accreditation and license. If health ministry requires mid-wifery, the state should make a tacit policy as well as the Education Ministry, National Planning Commission (NPC) and other bodies should make a joint commitment for requirement of nursing education. The first BSC nursing producer was BPKIHS. The state lacks policy on nursing education. We asked the government bodies, whether they require a fully qualified skilled nurse? While making future plans, we are ready to diminish fees for monitoring and accreditation by 60% to ensure nurses and clinical hospitals in outlying districts. Quality is a must, but for it, the state, public and all stakeholders have to be responsible. It is unfortunate that hospitals are taking 40 nurses for 50 beds hospitals while to meet the global standard 1:3 nurses are required. At least one student should get to learn from 2 patients. It’s very challenging to maintain the standard. Council alone cannot do it, a joint mechanism of professionals, inter-sectoral coordination, community leaders and most importantly political commitment is needed with careful planning of manpower for quality production and recruitment. So, the state has to be responsible first for quality production. Presently 41,000 ANM and nurses are registered in the council. No replacement has been made for retired nurses. Presently, Nepal needs an additional 13,000 ANMs. The private sector is doing good business, whose quality is questionable.

17


6. Dr. Mukti Ram Shrestha, representing for safety and security of Medical HRH:

We discussed a lot on medical workforce. To protect the rights of medical practitioners, the organization was established in 2007 BS. Since then, it has been working for the betterment and welfare of medical practitioners. It has been contributing to health sector to sensitize every sector from education, health to finance in order to address HRH issues and providing recommendations along with the formation of different committees. It also interacts with the health service consumers to bridge the gap between consumers and providers. It has also been urging the government, administration, police, the home ministry to address and control violence against the health professionals. We also provide scholarships to the deceased members' children. The Association now has many responsibilities. We are discussing with the Home Ministry and Police and district administration on how the attacks on hospitals and medical institutions can be controlled. We are organizing interaction with media and stakeholders to bridge the gap between service seekers and providers. For quality control, the responsible institutions alongside the association should work together. Medical association also took part in political movements for the change in the country. Regarding quality, the Association has been publishing a journal, running medical educational programmes for members’ knowledge enhancement, academic activities and also set up a library/study center. We are trying to facilitate legal reforms to stop attacks on hospitals by making the authority concerned to enact necessary laws. 7. Mr. Ram Bhandari, representing for Safety and security and quality of Public

Health professionals IOM started the curriculum of BPH. There are over 2 dozen colleges which run BPH courses. Annually, about 1000 students enrol in undergraduate programmes, mainly in private colleges. So the private sectors contribution is largely seen. It is the state's duty to guarantee education and health. The education fee in the private is quite similar to public institution, so I think the state should also promote and facilitate the private sector. Since, the private sector lives on competition, they survive through maintaining quality, in principle. They do not get adequate number of students, so they launch schemes. They are not in the position to hire full-time teachers. The association also interacts with the health service consumers to bridge the gap between consumers and providers. Investment should be made in quality and consistent teachers and there is a need for the cooperation between health and the education. The country’s unstable political situation is weakening educational institution. There is no public health council till now without which it is impossible to control the quality of education, production and utilization. It is important to regulate and improve the private sector for quality education to deliver quality health services.

8. Dr. Khem Karki, representing CSOs/NSAs Being the representative of Civil Society, we should find who are causing this terrible problem. We need to focus on several questions: What Civil Society organizations can do in this condition? How are they recognized by the state? Can we involve such organizations by putting their name alone? What WHO has told about such organization is "Social Power." So, we cannot meet any objectives denying the social power. We say, health service is for people, but if we forget "by people" and "with people" the problem cannot be addressed. Will there be anyone who can include and invest on people? What are the social responsibilities of those who are investing in these sectors? These needs should be understood fully. The production alone doesn't help but the quality of production should be

18


focused. We need to correct it from the point it has been ruined. First, we need political parties to make a commitment. Every government and non government institutions should collaborate with local bodies and civil society to get safety and security. If they call civil society only at the time of crisis, we cannot do more. Seriously, people's feeling has to be understood, community medicines should not be neglected. Civil society can help medical institutions to make cordial relation with locals and community. We never invest for profit. If our role is revised and formalized, civil society can invest a lot in public health service. CSOs can play their role in:

‐ Bridging the gap between health service providers and consumers. ‐ Increasing access to health services. ‐ Controlling investment for profit. ‐ Sensitizing political parties and drawing their commitment ‐ Safety and security of health professionals.

After the deliberation of the panel members, Dr. Tirtha Rana the moderator of the panel discussion session thanked all the panel members for their important presentations and bringing eminent issues on HRH at the surface level in regard to; policy and planning issues, quality of production of a variety of HRH (including of professional, paraprofessional levels), standardisation and quality control of HRH producing institutions such as medical colleges, nursing campuses and other institutions affiliated with CTEVT, role of state in maintaining quality of production of HRH, and problems and constraints of professional councils. Absence of Public Health Council and its establishment was pointed out. She explained that due to lack of adequate time to invite all the important institutions limited the participation of Health Professional Council. She expressed her gratitude to all the participants for raising important issues in regard to HRH in this panel discussion.

19


CONFERENCE RECOMMENDATIONS

The National conference ended by preparing the recommendations which demands strong leadership of Government of Nepal to resolve the health workforce shortage with strong will and commitment. The following are the recommendations to improve the HRH situation of the country:

International agencies, academic institutions, health care professional councils and associations, civil society organizations and other non-state actors need to complement and supplement the government to include distinct HRH related policies in upcoming national health policy and implement Human Resources for Health strategic Plan (2011-2015) with adequate funding in place.

The government has to come up with innovative incentive package, career prospects and measures for attraction and retention of health work force in under-served areas.

Health workforces of all levels need to be involved in policy making, planning and ensure implementation of health programs to deliver quality service.

The political parties need to be committed to invest in health sector focussed on quality human resources, advocacy and sensitisation to political leaders is important tool for their commitment.

Ministry of Health and Population need to focus more on quality of Human Resources for Health besides the quantity.

Acknowledging the shortage of health workforce, immediate measures need to be applied to produce adequate health workforce in consideration of appropriate gender mix, attrition and retirement. There are very few female representation in policy and key decision making positions. There is a need for an immediate action to resolve the shortage and unmatched distribution of health workforce through inter-sectoral coordination with prime focus on the community based and other health professionals including specialised health work force.

Adequate focus needs to be provided in distribution of work force related to pharmaceutical and drug administration, biomedical science, health economics and health care financing, health governance, hospital management & administration and health metrics and ayurveda, alternative medicine including a team of para-professionals in all of the above science.

For effective retention of the health workforce safe working environment, comfortable residence, effective communication, clinical coordination amongst health workers, continuous quality improvement and continuing medical education (CME) responsive to service demands and creativity need to be adopted. The benchmark of each level of institution need to be properly defined and backed up with resources.

Deployment, placement and retention of health workers to rural areas also demand provision of incentives, both financial and non-financial. Among financial incentives appropriate financial package such as: remote area allowance, health insurance, etc. should be provided to the health workers whereas on non-financial side, academic incentives, career development, timely transfer, security, recognition and respect should be provided.

Action oriented monitoring and supportive supervision of the health workforce at the work station should be strengthened.

Clear job description of health cadres need to be provided.

20


Performance based incentive, objective monitoring and evaluation and scaling up of education and training demands need to be strengthened.

The medical and public health education training needs to focus on communication, skills, moral and medical ethics, social responsibility and accountability.

The process to assess the quality has been limited to knowledge which needs to be expanded to include attitude and behavior of the health workforce.

Post training follow-up needs to be applied for all health cadres at the work setting to assure quality performance.

Acknowledging the contribution of the private sector positively helps them to enhance quality of training institutions and health workforce. Therefore, state and non-state actors need to work closely to strengthen partnership, leadership and management capacity from peripheral to central level. The private institutions need to complement to provide free basic health service.

The products of the institutions (especially medical doctors) need to have exposure at government health institution outside metro and sub metropolitan.

The current criteria for enrolment for nursing education need to be revisited. There is a need to establish public health council. There is the need to assess the trend of brain drain and identify the factors

contributing for this trend. Brain drain needs to be taken as global phenomenon and seek avenues for brain

drain to brain gain. Nepalese diaspora related to health sector need to be attracted and utilised.

Nepal seeks the relevance of developing code of practice on the international recruitment of health personnel.

Government and media need to go hand in hand to address the human resources for health issues.

Adequate proportion of health sector funding should be allocated to health work force production.

Multilateral organizations need to provide sustained and adequate support. Strengthening human resource information system is a must for better planning in

HRH. There is a need for more research to explore the production and supply of health

work force in Nepal to project the real demand of health cadres at all levels. Acknowledging the importance of Human Resource for Health, continuation of HRH

Conference is recommended to be held annually or biannually. In the long term Government should consider medical and health professional

education to be located within the Health Sector to match the provider and consumer needs and fulfilment.

21


ABSTRACTS

THEME: HRH STATUS IN NEPAL

Human Resources for Health Production in Nepal

Rajendra Prasad Gupta1, Jagadishwor Ghimire1, Raj Kumar Mahato1, Niranjan Thapa1, Arjun Kumal1, Ashmita Hada1, Deepak Kumar Bishwakarma1, Dr. Rajendra Kumar B.C2.

1 Save the Children

2 Consultant, DRC

Correspondence: Rajendra Prasad Gupta, [email protected]

Background: Acute shortage of HRH is apparent as Nepal has less than one third of the WHO benchmark on the number of health professional per 10,000 population. The HRH strategic plan 2011-2015 has tried to address the mismatch between demand and production of HRH. There is a demand for more SBAs, MDGPs, Gynecologists, Anesthetists, and Radiologists than other categories of health workforce. The country has seen drastically increased number of institutions producing HRH in Nepal. However, the absence of adequate and effective monitoring and reporting system on their outcomes has made challenging the task of keeping track of the changes in the numbers of health professionals in Nepal. In addition, the National Health Training Center takes care of developing capacity and skills of HRH in Nepal by offering different long and short term trainings. This study was undertaken to find out the situation of HRH production in public, private, academic and other related institutions, and describe the various kinds of trainings provided to HRH. Methods: This cross sectional study was conducted from September 2012 to February 2013. Even with the primary focus was on the quantitative method by using the format for the data collection, ten FGDs and six KII were also applied to generate qualitative information from different stakeholders. The finding was analysed and tabulated in the summary form and the qualitative part was analysed through content analysis.

Results: Council of Technical Education & Vocational Training (CTEVT) is the only institution offering technical and vocational education/training through majority of 294 institutions to mid and lower level health workers. In addition, few colleges of TU, KU, BPKIHS and NAMS are also offering Certificate or Diploma level programs. Staff nurses and CMAs have been produced by the maximum number of health institutions [101 (34%) and 76 (26%) respectively] in Nepal, whereas ANM, HA and Lab Tech have been produced by 15 -16 percent institutions.

There are 101 health institutions capable of producing 4,017 staff nurses each year, while only 1,451 graduate annually. The annual production capacity for HAs and Lab Technicians is 1,902 and 1,320 respectively but only 631 HAs and 102 Lab Technicians graduate. Such scenarios have also been observed in all disciplines (Pharmacy, Radiology, Dental, Ophthalmic Sciences, Ayurveda and Homeopathy). BSc Nursing program is run by 28 colleges, while PBN program in 25 colleges while MN by 2 institutions. There are 21 colleges for BPH program and 4 for MPH, whereas B Pharm program is found to be run by 11 colleges. Although Nepal has a capacity to produce 1,760 MBBS doctors from 18 medical colleges and 370 BDS doctors each year from 12 colleges, only 1,074 Nepali MBBS doctors

22


and 296 BDS doctors graduate per year. In the same way, Nepal has a capacity to produce 267 MD doctors, 116 MS doctors and 32 MDS each year, only 222 Nepali MD doctors, 95 MS doctors and 32 MDS doctors graduate per year. Various seats have been reserved for foreign nationals who studied MBBS in Nepal. There are some seats reserved for foreign nationals who studied MD/MS in Nepal. Three medical colleges are capable of producing 14 MDGP, 13 MCh and 18 DM doctors. However, 10 MDGPs, seven MCh and eight DM doctors have been found to be graduating every year. Similarly, the capacity for producing other health category cadres, including BPH, B Pharmacy is also underutilized. Moreover, new subject areas of health like B Optometry, BASL, B Sc MIT are also introduced and have begun to produce HRH. Each year 14 M Pharma and more than 6 MN have been found to be graduating in Nepal. Nepal has also started PhD program in health sciences particularly in public health, microbiology and pharmacy.

By the fiscal year 2010/11, the total production of CMAs was 55,152 CMAs, ANMs 18,142, Staff Nurses 18,391, 3,250 AAHWs, 2,704 HAs, 2,150 SBAs, 15105 Paramedics, 12,194 Medical Doctors and 106 MDGPs. The consumption of these health cadres in public sector is found to be maximum among paramedics (50%), HAs (46%) and SBAs (46%) followed by MDGPs (32%), Medical Doctors (12%), ANM (10%) and Staff Nurses (6%).

The national health training caters to the need of MoHP/DoHS for developing trained human resource. The central level is equipped with 33 approved positions but only 27% of them are technical positions. All kinds (34) of health trainings have been delivered through the network of NHTC, five RHTCs, one Sub-RHTC, 30 district training facilities and 14 training HPs in appropriate areas. In addition to this, there are 18 clinical training sites attached to regional and zonal hospitals which provide clinical competency based training in the area of family planning, safe motherhood and clinical service management. Three trainings with highest number of participants include training on Skilled Birth Attendance (895 participants), Communicable Disease Control (500 participants) and Gender-based Violence and conflict management (320 participants). The SBA production capacity of the country is unknown but each year the production is 900 SBAs of all categories.

Conclusions and Recommendations: The health institutions performance is lower in producing HRH compared to their capacity. A long-term effort is now required to match demand and supply of the HRHs; this will require major support from MoHP, NHTC, CTEVT, and academic institutions. The mechanism of quality supervision, monitoring, follow-up, and evaluation of academic institutions involved in HRH production and also their on-going teaching activities in co-ordination with relevant stakeholders need to be strengthened from the MoHP, MoE and Councils. Evidence based research on training should be conducted in order to explore ways to improve quality of training as well as training efficiency and effectiveness. Ensuring continuous improvements in training approaches through scaling up good practices and revision of training materials in line with Gender Equality Social Inclusion principles is also crucial.

23


Human Resources for Health in Nepal: A National Situational Analysis

Anant K Nepal1, Chandika Shrestha1, Achyut Karki2

1 Medical Emergency Relief International, Nepal 2Society for Local Integrated Development, Nepal Correspondence: Anant K Nepal, Merlin Nepal, Kupondole-1, Lalitpur | PO Box: 8975, EPC 1641, Kathmandu, Tel: +977-1-5544 450/250, [email protected] Introduction: Nepal encounters several challenges in Human Resources for Health (HRH) i.e. absolute shortages, inadequate competencies, uneven-distribution and improper HRH management. Despite these issues being highlighted in various national and international forums, there has been little effort to systematically analyse and address the underlying challenges. Therefore, to ensure a functional HRH mechanism in Nepal, empirical evidence is required to highlight the underlying issues, key gaps and existing challenges in the system.

Methods: A situational analysis was carried out through a review of the current literatures, key stakeholder consultations, institutional surveys and review of existing human resources for health mechanisms.

Results: In Nepal, health personnel to population ratio reported 16 per 10,000 population, which is below the ‘threshold’ density of 23 personnel outlined by the World Health Organisation (WHO), to achieve the health related Millennium Development Goals.

The public sector enrolment represents very low ratio (4.78), indicating a significant challenge to meet the WHO recommended standard. Only 29.27% of registered personnel work in the public sector, while the location of the remaining is unclear. Among all registered, two-thirds of health staff are working in either the Kathmandu valley or in other cities, leaving rural areas under-staffed.

Among all health workforce, only 4.3% were doctors, 24.2% were nurses and nearly half (43.5%) were paramedical revealing that semi-skilled and un-skilled support staff constituted 70% of the health workforce.

The disparity in the geographical location of training institutes was noted with the majority of them being located in the hill belt and central region. More than half of the institutions i.e. Medical (58%), Nursing (57.6%) and Paramedical institutions (51%) were located at hill followed by terai belt and very least in mountain belt. Similarly, more than half of them were in the central region. The provisions of temporary or contract basis recruitment were available at local level through government and local funds. However, there was no further career development or opportunity for in-service training for the contract staff members.

Low retention rates and overall de-motivation can also be attributed to the quality of working conditions: remote areas having less in terms of adequate and/or attractive salaries and allowances, lack of diagnostic facilities, lack of staff quarters with basic facilities, lack of social security (benefits) and fewer private practice opportunities.

24


Though emphasis was given to private sector’s involvement in health care delivery, the progress has been slow. However, many forms of partnerships existed.

Conclusion: Although there was sufficient production of HRH in Nepal with the involvement of the private sector, the shortage was still acute particularly in remote areas. The disparity in distribution of health workforce existed across the country and the supply has not met the need of growing population.

The HRH issues need to be addressed in health policies as required along with the effective implementation. Besides, human resource unit at the Ministry of Health and Population needs to be strengthened to make it more functional and monitor the new HRH strategy. Similarly, better coordination between the public and the private sector is a must to strengthen the partnership

Situational Analysis of Human Resource for Health in Public and Private Sectors in Nepal

Britain Nepal Medical Trust

Correspondence: Rinju KC, [email protected]

Background: In Nepal, private sector has emerged as a substantial force in HRH production and utilization, which needs acknowledgement and proper coordination between the public sectors engaged in HRH production and utilization to maximize the gains and better health impacts.

Objectives: To review existing global and national HRH related polices, plan, identify gaps and to recommend for better synergy in fostering healthy public private partnership for health workforce production and management in health sector in Nepal.

Methods: The study adopted a mixed method. The qualitative arm included in-depth interviews with health workers, officials and head of department from different private and public health institutions. The quantitative arm included literatures and desk review of policies available from different sources and analyzed. The study included respondents from public and private institutions across four development regions and covered major districts namely Kailali, Banke, Kathmandu, Sunsari, Dhankuta and Morang. The duration of the study was four months from September to December 2011.

Results: Human Resource for Health is formally produced in Nepal through different mechanisms under the Ministry of Education and the Ministry of Health and Population. Visibly, there are a large number of private health institutions that are involved in training of different specialty and level of HRH. These institutions produce abundant number of health workforce required to serve large number of growing population, even to the extent of supplying to the global market. However, quality is seriously compromised as compared to government colleges. The concentration of human resource is high in urban areas and private sectors. Among the nursing students, 57% expressed their desire to work for the private or NGO sector after graduation. Health workers from Public sectors were likely to be less dedicated towards their work compared to health workers from private sectors.

This study identified lack of well equipped quality infrastructure to enhance skills, low paid salary compared to private sectors, frequent transfer, limited scholarship programs for doctors, lack of career development opportunities and private practice in remote areas,

25


attitude of Medical doctors entering public sector for the sake of grabbing opportunities to study MD/MS, no upgrading system, no/weak linkages of central level offices with peripheral level, lack of recognition etc; as the causes for low retention of staffs in public sectors. Brain drain of human resources especially for doctors and nurses is a big problem in Nepal and needs to be addressed urgently.

Conclusion: The private sectors can make a big difference in the public sectors by producing HRH and delivering services to general population in proper coordination with public sectors working in their own area. Hence, there is a need to strengthen the public private partnership model to enhance quality of service and better HRH management.

National Status of Health Workforce in Nepal

Khem B Karki1

1 Society for Local Integrated Development, Nepal Correspondence: Khem B Karki, [email protected]

Introduction: Nepal, one of the countries with HRH crisis, as per the WHO threshold density of 23 health workforces per 10 thousand people for achieving MDGs, has been facing persistent challenges of poor performance (productivity, quality, and availability), fragmented health workforce planning and management, imbalance between supply and demand, narrow skill mix, low level of retention and high level of migration. This paper intends to highlight the burden of diseases versus preparedness of workforce, distribution, existing management system weaknesses and competencies of health workforce in Nepal

Methods: A thorough review of available research reports, MoHP documents and records, HRH Management system and stakeholder consultations was carried out as a part of the situation analysis of HRH in Nepal.

Results: A review of health workforce stock in Nepal shows that only 7.84 doctors, nurses and midwives are available for 10,000 people which is far less than critical threshold of 23 per 10,000 to achieve the health related Millennium Development Goals. Among all the health workers, 65 percent work in urban settings where only 17 percent of the total population resides. Moreover, 90 percent of doctors are in urban localities.

In the context of shifting disease pattern from communicable diseases to non-communicable diseases- 82 percent of OPD visits and 89 percent of hospital admissions are related to NCDs - only 17 percent of health workforce is oriented to NCDs. A series of reviews and stakeholder consultations confirm that human resource management system is almost non-functional. The system cannot provide the actual information on HRH related issues. Only half of the health workforce is available at duty stations at the time of conducting the research. Of them, one in three expressed himself/herself as incompetent to perform their given jobs. There is a huge gap range from 20 to 80 percent in basic essential competencies in midwifery curriculum of different levels of nurses in Nepal. Most of the peripheral hospitals and PHCC are filled by doctors hired in contract and temporary basis, who recently graduated and have no technical backstop.

26


Conclusion: Despite many challenges, some progress has been made towards achieving the MDGs but not sufficient. Moreover, increasing NCD burden and health demands of the people requires a thorough revision and reform of the education and training curricula for producing appropriate health workforce including a good skill mix. Human Resource Management System should be thoroughly reviewed and updated with compulsory registration of health workforce in a single system as a part of HMIS. A transparent transfer calendar, induction trainings and supportive supervision to newly recruited health workers should be in place to improve the status of the existing health workforce situation in Nepal.

Human Resources for Health in Ayurveda Sector in Nepal

Dr. Madhab Prasad Lamsal1

1Senior Integrated Medical Officer, Kanti Children Hospital Correspondence: Madhab Prasad Lamsal, [email protected]

Ayurveda College is the first ever educational institution in Nepal to produce Health professionals. In Nepal, since 1933 AD Ayurveda education and human resource development is mentioned in the National Ayurveda Health Policy. To provide quality services through research and training, the National Ayurveda Research and Training Centre has been established.

Ayurveda and Alternative Medicine Section under the Ministry of Health and Population is responsible to develop necessary planning, policies, rules & regulations regarding traditional medicine (TM) existing in the country and plays a vital role in co-operation, co-ordination, direction and monitoring other organizations related to TM . Medicine production and Ayurveda health services are being delivered through the public and private sectors under the Ministry of Health and Population. The Department of Ayurveda offers Ayurvedic care to the people and also implements health promotions such as yoga.

WHO report shows that about 80% people are using traditional medicine including Ayurveda. Mainly, the Government of People’s Republic of China, Government of India and WHO are providing financial and technical support for Ayurveda Human Resource development. Most of the Ayurveda practitioners are trained in Nepal, India and China.

A total 1, 170 practitioners are registered in Ayurveda Council (Doctors 361, Paramedics 790 and Traditional Practitioners 19). Formal Ayurvedic education in Nepal is under the Ministry of Education (TU, IOM, Nepal Sanskrit University and CTEVT).

Demand of Ayurveda Service is increasing but the work force in the area is inadequate. Low priority in terms of budget, research and training are the main distracting factors for Ayurvedic personnel.

The role of Ayurveda to achieve national and international goals and indicators is not explained or studied; inadequate formal justification about the successful treatment of certain diseases with Ayurveda therapy claimed by practitioner due to lack of research based services are the main challenges.

Quality and quantity work force problem should be addressed immediately by formulating the Master Plan. Action and clinical research should be conducted to promote quality

27


service and professionalism. Strong bond with other academicians like sociologists, botanists, and microbiologists should be developed in institutional basis.

THEME: DISTRIBUTION AND SKILL MIX IN NEPAL

Distribution and Skill Mix of Human Resources for Health in Nepal

Khakindra Bhandari1, Bhuwan Baral2, Khem B. Karki2

1 Medical Emergency Relief International, Nepal 2 Society for Local Integrated Development, Nepal

Correspondence: Khakindra Bhandari, Merlin Nepal, Kupondole-1, Lalitpur | PO Box: 8975, EPC 1641, Kathmandu, Tel: +977-1-5544 450/250, [email protected] Introduction: The Ministry of Health and Population (MoHP) of Nepal has identified major challenges in Human Resources for Health (HRH). This includes distribution and skill mix of health workers in the country. This report aims to provide insights into specific challenges and policy recommendations for MoHP and the stakeholders concerned. Methods: A descriptive study, using quantitative and qualitative methods, self-administered interview with 747 health workers from 375 institutions of 15 districts was carried out. The districts representing eco-developmental regions of Nepal were selected using multi-stage cluster sampling method. In-depth interviews with key respondents and focused group discussions with service providers, managers and users were also performed. Secondary review of data was conducted for triangulation of the findings. Statistical Package for the Social Sciences (SPSS) was used for statistical analysis. Results: In Nepal, mushrooming private academic institutions have led to relatively high production of some categories of health workforce like nurses, doctors and paramedics. However, their distribution is not equitable. By contrast, other health cadres are in low production (e.g. MDGP and surgeons). The available data were inconsistent, inaccurate and incomplete amongst different sources. The cumulative data of Medical and Nursing Council show 16 registered health workers per 10,000 population. Yet many registered health professionals have migrated, turned to private practice or retired. Furthermore, the public sector has a ratio of only 2.9 health workers (including doctors, nurses, and midwives) per 10,000 population which is far below the standards recommended by WHO - 23 health workers per 10,000 population to meet the health related MDGs. Despite the fact that the population has increased by 45 percent in last two decades, the number of sanctioned posts in public sector is still based on the 1991 Health Policy. Overall, 14 percent of the sanctioned positions for all health workers were vacant, with a 38 percent deficit of doctors in the surveyed districts. There were a low percentage of positions filled by doctors in private health facilities, partly due to cost-saving mechanisms of private facilities. It is also found that the absence of sanctioned posts for Auxiliary Nurse Midwives at the Sub Health Post level, recruitment was found to be carried out locally, based on the needs.

28


Only 43 percent of hospitals and 18 percent of Primary Health Care Centres had an appropriate skill mix. Furthermore, the in-service curriculum does not take into consideration the epidemiological shifts in the population, and despite the fact that the prevalence of non-communicable diseases (NCDs) is 36.5 percent, yet only 17.4 percent of Health Workers have received orientation or training on NCDs from government. Conclusion: There is scarcity of doctors and other health cadres in the public sector, particularly in rural areas. The skills of those serving in the health sector have also not been updated in line with changing disease trends and technological advances. The data available on HRH is limited and ambiguous. The number of sanctioned positions, categories of health workers and training curriculum should be revised to account for epidemiological shifts and population growth.

Optometrists as Human Resource for Health in Nepal

Dr. Subodh Gyawali1

1BP Eye Foundation

Correspondence: Subodh Gyawali <[email protected]>

Background: Optometry education started as a three-year course in Nepal in 1998 at, the Institute of Medicine, Tribhuvan University. Since 2005 it has been upgraded as four years course. The need of optometrists as human resource for health was identified by the Ministry of Health and Population to meet the goals of Vision 2020: The Right to Sight. So far only one university offers the course and every year six optometrists are produced. There are 56 optometrists practicing in Nepal at present. Present optometrist population ratio is 1:791,666 against the WHO recommended ratio of 1:50,000

Issues: Optometrists are not included as human resource for health in the "Health Services Act" of the MoHP, Government of Nepal. Only eye health professionals which are not produced in Nepal and very few in number are included. None of the optometrists are employed in public services. The Apex Body for Eye Health formed under MoHP is virtually non functional. It does not have representation from all the eye health professions that exist in Nepal. There is no national policy on how many categories of personnel are required for eye care in Nepal. There is no long term institutional plan for optometrists in Nepal. There is no opportunity for higher studies/ career path development within the country. As a result, an increasing number of graduates are migrating abroad.

The need: There is an increasing demand for optometrists within and beyond the country. More optometrists need to be produced. As uncorrected refractive error is the leading cause of ocular morbidity worldwide including Nepal. HRH dealing with refractive error correction should constitute the bulk of national eye health workers. It is essential to constitute a high level of multi-sectoral HRH policy and planning committee within MoHP with participation of the stakeholders concerned to formulate policy and draw a plan for HRH development.

29


Integration of Pharmaceutical Care in Health Services: Policy Review

Bhupendra Thapa1 1National Pharmaceutical Consultant Correspondence: Bhupendra Thapa, [email protected] Outcome of any treatment depends on the appropriate use of medicine. For rational use of medicine right medicine at right dose for right duration is required. However, due to lack of professional dispensing irrational and inadequate use of medicine is rampant. Involvement of pharmacist human resource is necessary for achieving this goal. Appropriately managed hospital pharmacy, and dispensing by pharmaceutical persons at the community pharmacy is needed. Government has endorsed necessity of pharmaceutical services in many policy documents. National Drug Policy, 1995 mentions that the drug related activities such as procurement, distribution, storage and dispensing at governmental as well as non-governmental institutions will be carried out by qualified pharmacy personnel. Pharmacists are involved in very few hospitals, and there is post of pharmacy assistant up to zonal hospitals. Strategic Plan for Human Resources for Health, 2003-2017 has envisaged involvement of pharmacists and pharmacy assistants up to district hospitals. Three-year Interim Plan for health mentions that the central, regional and zonal hospitals will be operating their own pharmacy, and district hospitals will be developed and equipped as referral hospitals for the district-based health institutions with adequate physical infrastructure, beds, human resources and necessary drugs and equipments. Private and Nongovernmental Health Institution Operation Guidelines mentions about the requirement of pharmacy operating 24 hours and involvement of pharmaceutical human resource there. Short duration orientation training programme conducted for producing dispensers has been discontinued and diploma level pharmacy education has been started to produce dispensers. To fulfill the growing need of pharmaceutical human resource, more than 1160 persons are enrolled for Diploma in Pharmacy course under Council for Technical Education and Vocational Training (CTEVT). Bachelor of Pharmacy course is conducted by four Universities within country and enrollment of student is more than 700 every year. Kathmandu University has started Doctor of Pharmacy (PharmD) course and the first batch will be in the market this year. Though the policy guidelines are available for integrating pharmaceutical care in our health services, the implementation aspect is far from satisfactory. Now it is timely that the policy guideline be implemented effectively for improving quality of care. This presentation will suggest the types of pharmaceutical personnel required at various level of health institutions, their role and responsibility and impact on the quality of health care by this provision.

30


Access to doctor: TB Services in Far Western Development Region (FWDR)

Dr. Suhubhesh Raj Kayastha1

1 Seti Zonal Hospital, Kailali Correspondence: Dr. Shubhesh kayastha: [email protected]

Background: Drug Resistance Tuberculosis (DR TB) is an alarming health problem and a serious challenge to Tuberculosis control program.

National Tuberculosis Program has undertaken four national survey of anti tuberculosis drug resistance. The first MDR TB survey was carried out in 1996-97. This showed resistance level of 1.2% among new TB cases. According to the latest survey (2011) the estimated prevalence of multi drug resistance TB (MDR TB) is 2.9% ( 95% CLs, 1.8-4.3 ) among new cases and 15.4 (95% CLs, 7.2-17.7 ) among retreatment cases.

DR TB program in Nepal started in Sept. 2005. Initially, five pilot sites were established in all five regions of the country for MDR TB program management. In the Farwestern Development region (FWDR), Mahakali Zonal Hospital initiated MDR TB management program since 2005. In order to improve the access of DRTB service in the region NTP expanded DR TB program to Kailali at Seti Zonal Hospital in 2009 and DR TB hostel was established in Kailali on 2011 with the expansion of two treatment sub centers in 2013.

An eight-year DR TB program management from 2005 – 2013 in FWDR has been reviewed focusing the DR TB patient profile, access to DR TB service in the region, program coverage and DR TB program indicators have been evaluated.

Results: A total 144 DR TB cases has been registered in FWDR. Out of 144, 3% of patients belong to initial resistance and 97% comprises retreatment population. Among the MDR TB patients 106 (73.61%) were male and 38 (23.69%) were female. The highest number of affected age group was 25-34 (31.25%) percentage. The access of DRTB service in different districts of the region was analyzed and revealed bigger number 62 (43%) of patients was enrolled in Kailali and secondly 11 (32%) in Kanchanpur. The least access districts were Bajhang, Darchula and Bajura, the enrollment was 0.7%, 1% and 1% respectively. There is a big discrepancy to access of service among the MDR TB patients within the region.

Extensively Drug Resistance Tuberculosis (XDR TB) Management was initiated since 2012 and total 9 patients have been diagnosed and 5 XDR TB patients are undergoing treatment. 40% of them belong to age 15-24 yrs.

HIV/AIDS is an emerging epidemic in FWDR which comprised 27% of national figure, a total 8 (5.5%) MDR TB patients are co infected with HIV infection and 1 (11.1%) XDR TB patient is co infected with HIV infection. The national case finding rate of MDR TB is 20%, the trend of case finding rate of FWDR is dramatically increasing by 90% due to hostel facilities.

Conclusions and Recommendations: To increase the case finding, there is an acute need and provision of Xene Xpert test at district level and Line Probe Assay facilities at zonal level with DST facility at regional level by establishing regional Laboratory facilities. Availability of hostel facilities is important for case holding, minimizing defaulter rate and ultimately to increase cure rate. Social support and income generating skill development

31


program in hostel is another important aspect. There should be a provision of proper training for different levels of health personnel and incorporation of national DR TB management guideline in medical graduate curriculum. Existing Infection control Program is very poor and should be improved at work place.

Success Stories of HRH Pilot Project in Lalitpur District: Case Study

Achut Babu Ojha1, Shanti Timalshina1, Gopal Bajgain1, Sangita Karki1, Kopila Koirala1

1 Rural Institution for Community Development (RICOD), Chapagaun, Lalitpur

Correspondence: Achut Babu Ojha, RICOD, Lalitpur: [email protected]

Dalchoki SHP on the Way to Providing a Conducive Working Environment for Quality Healthcare

Dalchoki Sub-Health Post (SHP) of Southern Lalitpur is not adequately equipped with minimum number of staff, materials and infrastructure. The SHP is providing services with only two health workers (i.e. 1 AHW and 1 ANM). HFOMC members do not regularly meet and they are unaware of their roles and responsibility.

After implementation of HRH-Pilot Project it was decided to start outreach clinic in ward no 2 and 7. For this, they decided to recruit one health worker with the VDC resource under RICOD HRH Pilot Project. HFOMC started to meet regularly and succeeded in developing an action plan for the development of SHP infrastructure and manage adequate human resource for health. During public hearing, community forest users group of Dalchoki VDC decided to provide required land from their forest area to construct new sub health post building. In the same public hearing program, one community resident donated NRs 1000 to purchase donation box which will be kept in SHP for the fund raising to construct SHP building.

Management of Technical Staff Through Civil Society Involvement in Lamatar - SHP

Ward no.9 of the VDC lies in a bit remote part of the district where an SHP is situated. The SHP is providing health services through three technical staffs continuously. Two MCH clinics are run in ward number 1 and 2 monthly. The major problem of SHP is that the staff are unable to give service throughout the week at the SHP. The Community people of ward no.9 are unable to get service on two days of the week as the staff have to run the ORC in the VDC. The Community people of other wards were demanding more health facility from ORC for a long time. HFOMC decided to recruit one technical staff with the support of VDC and RICOD HRH Pilot project. HFOMC started to meet monthly to follow up on the action plan developed by them. We developed MOU between HFOMC, VDC and RICOD HRH Pilot project for the recruitment of an ANM for which financial support will be extended by RICOD (for 6 month) and Lamatar VDC (for 12 months). Similarly, VDC secretary shows his commitment to support for upcoming years too.

32


Role of HFOMC in Lele PHC for HRH Management: An Example

Lele PHC is providing health services in spite of absence of Lab assistant they are trying to give quality service. They were equipped with X-ray machine which was in support of Lele VDC but they were unable to utilize it due to the absence of trained technician.

HFOMC of Lele PHC requested many times to fulfil the vacant post of lab assistant in DPHO but their requests were not addressed. Therefore they decided not to support DPHO activities in their institution. Because of the same reason they resisted RICOD-HRH Pilot project also.

After a series of meetings we were able to convince them to stay in joint meetings with DPHO in imitation of RICOD. It was decided, during the meeting, to fulfil the vacant post of a lab assistant within one week and DPHO also assured to manage a training to operate the available X-ray machine for one AHW of Lele PHC.

At present, the vacant post of the lab assistant is fulfilled and he has started the lab service at the PHCC. Staff are regular at PHCC and they are also following the duty roster and as a result, the patient flow is increasing day by day.

33


THEME: DEPLOYMENT, PLACEMENT AND RETENTION OF HRH

Responding to Increased Demand for Institutional Childbirths at Referral Hospitals in Nepal: Implications for Human Resources

Prof. Dr. Madhu Dixit Devkota1, Dr. Devi Prasad Prasai2, Dr. Senendra Raj Upreti3, Dr Shilu

Aryal3, Dr. Ganga Shakya2, Dr Maureen Dariang2, Mr. Jagadishwor Ghimire4 1 TU, IOM, Department of Community Medicine and Public Health 2 NHSSP, Teku, Kathmandu 3 FHD, Teku 4 Save the Children Correspondence: Prof. Dr. Madhu Dixit Devkota, [email protected] Background: Government of Nepal is committed to providing skilled care to women during childbirth, in line with millennium development goal target of 60% of births assisted by a Skilled Birth Attendants by 2015. To reduce financial barriers, the Aama Surakshya Programme provides free delivery care to women, fixed payments to institutions to provide services, and transportation costs to mothers. The country has made significant progress in maternal health in the last 20 years with the reduction of the maternal mortality ratio from 539 to 170 deaths per 100,000 live births. In addition, the proportion of deliveries at health institutions has also increased almost fourfold from 9% in 1996 to 35% in 2011. Methods: This study, conducted by Family Health Division, with the support of DFID/Options, aims to address the question, whether increasing utilisation of referral hospitals for delivery care had outstripped supply and was compromising Quality of Care. Six hospitals (out of a national total of 17) were selected purposively to represent the country’s development and ecological regions. The study used quantitative and qualitative approaches along with desk review, formation, and engagement of a key informant group of experts, and fieldwork to achieve its objectives. Results: The study found that in Terai and easy-access hill areas, 88% of all institutional births took place in the hospitals. Almost all (98%) mothers bypassed birthing centres and came directly to hospitals. The maternity wards of the hospital were over-crowed, with bed occupancy rates ranging between 80-145%. The monthly maternity bed occupancy rates were also consistently higher than the World Health Organization standards of 80% for most months, indicating compromised Quality of Care. The supply side had not been complemented by the increment in demand, with very few additional beds, infrastructure, or human resources made available at the referral hospitals in the last 15 years. The shortage of health workers had seriously compromised the quality of maternity services. The sanctioned positions for health workers, which determined the number, the skill mix, and the expertise had not been revised and therefore did not address the present-day realities of increased demand for services. Even these sanctioned positions were not filled, adding to the chagrin of the very limited number of health workers who actually provided services. Key managerial positions (medical superintendent, matrons, and nursing supervisors) lay vacant at all the hospitals. Less than half (45%) of the obstetrician/gynecologist positions were filled. More than 60% of the sanctioned anaesthetist

34


positions also were vacant, with three zonal hospitals (SZH, BZH, and JZH) out of the six managing without an anaesthetist. Anaesthetic Assistants were providing services, defying the rule that allowed them to provide services only under the supervision of an anaesthetist or a doctor trained in anaesthesia. To make up for the dearth of personnel, the HDB hired HR locally. However, a number of problems from policy to its implementation existed. The contracted SBAs (nursing staff, doctors and other) had heavier workload and received less remuneration than regular government staff. Conclusions and Recommendations: The study recommends making an additional 426 beds available to accommodate the existing and future demand until 2015 to meet the standards in order to address over-crowding. Similarly, the gap of 148 nurses and 28 doctors in these six hospitals must be addressed to meet the WHO (2005) benchmark of four doctors and 20 nurses for 3,500 births to assure quality of care. The cost of filling these posts would amount to NRs. 50 million per year which was urgently needed.

Predictors for the Choice of Future Practice Location among Graduating Medical Students: Perspective from Social Cognitive Career Theory in Nepal

Bhim Prasad Sapkota1

1 Ramghat Health Center, District Public Health Office, Kathmandu

Correspondence: Bhim Prasad Sapkota, [email protected] Introduction: Nepal is facing the same problem of health care workers maldistribution as the rest of the ‘two thirds’ world. The migration of health workers from Nepal is a major problem, although it is poorly documented. Many doctors leave Nepal to work abroad and many of them within Nepal migrate from rural to urban location, though the magnitude of this migration has not been quantified. Objective: To explore the predictors for choice of future practice location and to explore the perceptions of medical students and their attitudes towards placement choices after graduation through the perspective of socio cognitive career theory (SCCT). Methods: It was a cross sectional descriptive study conducted among medical students studying in the final year MBBS and doing internship. Among eighteen medical colleges, only ten were taken as sampling frame. Anonymous self administered questionnaire was used for data collection from 393 students. Demographic factors, economic factors and educational factors were compared with the SCCT related factors as their association with within country, public sector and rural location choice. Findings: Among 393 respondents two thirds were male (66.9%) and more than half were of below 25 years of age. About two thirds (64.1%) of the respondents had rural birth place while 58.8% and 53.3% had place of rearing and permanent address in rural locations respectively. In multivariate analysis, higher wealth ranked respondents were found to be less than one (AOR= 0.394) time likely to be associated and non-distinction scorer in higher secondary education were four (AOR=4.005) times likely to be associated with the within country choice. For public sector choice, public college for higher secondary level education (AOR=3.338, CI=1.132-9.847) was found to be associated. Among four constructs of SCCT framework goal mechanism was found to be associated (OR= 2.031, CI= 1.049-3.931) but not found in adjusted association. For rural location choice, in multivariate analysis, better confidence on professional outcome expectation (AOR=1.935, CI=1.01-3.528), rural location of secondary education (AOR=3.706, CI=1.247-1.545) and rural location of rearing

35


(AOR=4.390, CI=1.787-7.687) were found to be associated. Among four constructs of SCCT variables, self efficacy (OR=1.644, CI=1.007-2.685) and professional outcome expectation (OR=2.075, CI=1.262-3.412) were found to be associated. Conclusion and Policy Implications: Higher wealth rank of the family had shown inverse association with within country choice. It indicates that access of lower wealth rank family to the medical education should be increased. For public sector choice, public college for higher secondary level education was found to be an ultimate predictor. It indicates that to attract the doctors towards public sector, students who had completed their HSS at public college should be promoted. For rural location choice, location of secondary education and rural location of rearing were found to be associated as predictors. It indicates that to attract the doctors in rural location educational policy should be revised so as to increase the access of medical education to the students from rural location.

Nursing Human Resources on Present Situation and Its Attractions and Operation at Standard Guideline of Nursing Workforce

Mrs. Ishwori Devi Shrestha1

1Chief Nurse Administrator, Ministry of Health and Population

Correspondence: Mrs. Ishwori Devi Shrestha, [email protected]

Background: Nurses are crucial human resources for any national health system of the country. The nursing care depends upon the motivation of nurses towards their jobs. A descriptive study on nursing human resources in the present situation, its attraction and operation was done in 2011/2012 by nursing service unit of curative division, MOHP. The objective of study was to find out the nursing service situation, attraction and nursing workforce distribution for quality nursing services and to formulate the standard operation guideline for quality nursing service delivery from government, community and private sector in Nepal.

Methods: This study was a descriptive cross sectional study. The study was mainly conducted by visiting individual nurses at their institutions, interview and group discussions with them. The review of existing documentation at national and international level along with interactions with experts was also carried out during the study. There were involved nineteen institutions – Bir Hospital, Kanti Children Hospital, Teaching Hospital, Maternity Hospital, Gangalal Heart Hospital, Surkhet Hospital, Bhaktapur Hospital, Patan Hospital, Beni Zonal Hospital, Regional Hospital Pokhara, Koshi Zonal Hospital, Om Hospital, Western Private Hospital Nepalgung, Neuro Hospital Biratnagar, Stupa Community Hospital Kathmandu and Manipal Medical Collage. The interview/ discussion were also done with medical directors and nurses.

Findings: Nurse’s ratio in indoor services of hospitals was found that this was poor in all the hospitals. For Bir hospital, a total of 451 beds was there while total nurses working were only 248, indicating the ratios according to beds for 24 hour of 1:81. There were 46 vacant posts of nursing cadre. For Kanti children hospital, total bed was 309 while nurses working there were 84, 3 positions were vacant. The ratio according to beds for 24 hour was found to be 1:67. In Teaching hospital (TUTH), total 506 beds were there while 402 nurses were working at the time of survey, the ratio according to beds for 24 hr was 1:25. In Paropakar Maternity Hospital there were 415 beds and 171nurses leading to the ratio 2:20, with the vacant post of 3 nurses. In GangaLal Heart Centre, there were a total of 160 beds and 171 nurses, with the ratio according to beds 24 hr of 1:1. In Patan hospital, total

36


beds were 400 and nurses were 325 and the ratio according to beds 24 hr was 1:23 with vacant nursing positions of 6 nurses. In Bhaktapur hospital, the ratio was 3:41. In Sub regional hospital surkhet, total bed were 50 while nurses working were 21, the ratio according to beds was 2:4 and 2 vacant positions of nurses. In Bheri Zonal Hospital, there were 150 beds and 45 currently working nurses with the ratio according to beds of 1:11 and 4 vacant post. In Western regional hospital pokhara, a total of 325 beds were available and 143 nurses were working. The ration according to beds 24 hr was 2:27 with the vacant post of 2.

Recommendations: There is urgency of National standard operational guideline for quality nursing servicemen. Besides, a regular monitoring and supervision is must for enhancing nursing services. The study further demands for the establishing nursing division.

Training, Recruitment, Placement and Retention of Health Workforce in Nepal

Raju Prajapati1, Khem Karki1, Bhuwan Baral1

1 Society for Local Integrated Development NepaL (SOLID Nepal), Satdobato, Lalitpur

Correspondence: Raju Prajapati, [email protected]

Introduction: A trained and skilled health workforce at the right place with adequate motivation and support are crucial to achieving the MDG targets by 2015. Despite a concerted effort in Nepal to provide a national system approach for the recruitment and placement of such health workforce, the system is found to be fragmented, politicised and subject to exploitation. Furthermore, attraction and retention of qualified and skilled health workers, especially in rural and remote areas remains a challenging issue for the Nepal health system. Methods: A cross-sectional descriptive study was conducted using mixed method (quantitative and qualitative) with observation checklist. Fifteen districts representing eco-developmental regions of Nepal were selected using multi-stage cluster sampling method. Out of 404 sampled institutions, 747 health workforce from 375 health institutions were interviewed (<10% non-response rate) using the Probability Proportionate to Size method as per WHO guideline. Observation was carried out in 256 health facilities. Data analysis was done using SPSS v16. Further, secondary review was carried out for triangulation of findings.

Findings: Majority of the academic institutions for HRH production are privately owned and urban located. These are some of the contributing factors to the critical shortage of health workers in rural areas. In total, 89.9 percent of academic institutions are privately owned, 96 percent of academic institutions are in urban areas, and 58 percent are located in the Central Region. By contrast, only 2.4 percent are located in the Mountain belt and 2.9 percent are in the Far-Western Region. Very low numbers of in-service training courses are offered to private institutions (14.6 %) and Ayurvedic Centres (8.6 %). Less than half of doctors (42.8 %) are trained in maternal and child health. A common theme among respondents was the need for training to be updated on a continual basis taking into consideration policy changes, disease patterns and new technologies.

37


The recruitment process for permanent position is time-consuming, inflexible, and impractical, and is flawed in that staff are often upgraded based on the length of their service period, rather than based on knowledge and skills. Health workers are often not provided with the job description for a new role, which is often a barrier for further promotion within the health system. There is a significant gender disparity in types of work placement, in that female respondents were less likely than male respondents to work in permanent contracts (49.5% females, 76% males), and were subsequently more likely to work on a temporary contract or daily wage basis (42.4% females, 22.3% males). This raises concerns around the recruitment process at central level. The nature of transfers is haphazard, and hampers performance within the health system, de-motivating health workers. Conclusion and Recommendation: The inequities in access to medical education, and inadequate regulatory mechanisms for recruitment, placement and promotion, resulted in poor retention and shortages of health workforce in Nepal. These issues could be addressed through utilisation of private resources and expertise to complement public sector endeavours.

38


THEME: CAREER DEVELOPMENT, EDUCATION AND TRAINING FOR HRH

Career intentions of medical students in Nepal

Ian Huntington1, Suvash Shrestha1, Nicholas G Reich1, Amy Hagopian1

1Kathmandu Medical College Correspondence: Dr. Sunil Kumar Joshi, Associate Professor of Community Medicine Kathmandu Medical College, Sinamangal, [email protected] Background: In the last two decades, the number of medical schools in Nepal has increased significantly, and so has the number of young graduates. This rapid expansion of medical community can be expected to solve the problem of scarce human resources in health in Nepal, especially the rural areas. But it does not seem to be true in practice because it is unknown where this expanding cohort of new physicians will ultimately practice. Methodology: We distributed an anonymous survey to students in their last 2 years of medical school at four medical schools in Kathmandu Valley – Kathmandu medical college, Nepal medical college, Institute of Medicine and Kathmandu University School of medical sciences - to study two dimensions of career intention: the intention to practice in Nepal and the intention to practice in rural areas. Results: Eighty-five per cent of the eligible study population participated, for a total of 469 medical students. Of these, 88% thought it was likely they would practice in Nepal and 88% thought it likely they would practice in urban areas. Those students, who indicated a greater likelihood of practicing abroad came from families with higher incomes, were more likely to think earning a good salary was very important to their decision to become a physician, and were less likely to think they could earn a good salary in Nepal. Students whose tuition was paid by the government were no more likely to indicate an intention to practice in Nepal than students paying their own tuition at private medical schools. Students who indicated a greater likelihood of practicing in rural areas were more likely to be male, to have gone to a government secondary school, to have been born in a village, or to have received a scholarship from the Ministry of Education that requires rural service. Conclusions: Based on our findings, we suggest the following policy changes: (1) Ministry of Education give priority to students from rural backgrounds during selection for scholarships program, (2) medical schools also consider selecting for students from rural backgrounds or government secondary schools who are more likely to intend to practice in rural areas, and (3) increase the number of post-graduate positions—weighted toward rural health needs—to retain students in Nepal.

39


Beyond Training – The Follow-up Enhancement Program

Shovana Rai1

1Nick Simons Institute, Sanepa, Lalitpur, Nepal

Correspondence: Shovana Rai, [email protected]

Background: Pre-service and in-service training occurs at a break-neck pace right across Nepal. But what happens to the graduates?: are they in the right posts? do they retain their skills? do they have adequate equipment and management support? The Health Ministry’s National Health Training Centre (NHTC) mandates that 20% of trainees be followed up in the field, but in reality much less than that takes place.

Intervention: Under NHTC, NSI developed a series of tools called the Follow-up Enhancement Program (FEP). This program facilitates for in-service trainers to visit graduates in their place of work. This 1- to 2-day visit includes a knowledge and skills assessment of the graduate, a coaching session, and assessment of the enabling environment. This leads to feedback at various levels: to the graduate themselves, their supervisor, the district health officer, training sites, and to officials in the Health Ministry.

Results: Over the last two years, FEP has been conducted on a total 553 graduates of NHTC training courses. This constituted from 8 to 48% of the total graduates within each of the cadre pools. FEP teams visited nearly half of the districts in Nepal.

Training Number FEP Participants

Total Number Graduates

Skilled Birth Attendant 339 4031 Mid-Level Practicum 114 450 Biomedical Equipment Tech 30 78 Ultrasound 26 61 Anesthesia Assistant 44 94

A range of useful information was discovered, which would not have been uncovered by any other means. For example: (1) Graduates were much stronger in certain skills than in others – this is being used to modify existing training programs; (2) Some graduates were not in the right posts to use their skills – this is being used to advocate for proper deployment; (3) Graduates from certain training sites were weaker – which enables to give those sites special attention; (4) There were many gaps in essential equipment – something to feed back to Department of Health Services.

Conclusion: FEP should become an essential, built-in component of any health care training program in Nepal. Without this follow-up information, the training community may be working in the dark.

40


Human Resources for Health: Career Development Perspectives

Shankar Raj Lamichhane1

1Maharajgunj Medical Campus, IOM

Correspondence: Shankar Lamichhane: [email protected]

Background: Health workers are all those who are engaged in actions whose primary intent is to enhance health. People love to work at organizations or services if they see career prospects in them. No one wishes to waste years of hard work and skills. For this career development opportunity in an organization is a must for HR retention and to increase their efficiency as well. It is a bitter irony that our country spends millions of rupees in medical education but in the end, a medical student chooses a foreign land for better opportunity and career development.

Keeping this in mind a study was done by Medical students of Maharajgunj medical campus from 26th May to 29th May 2013 in Mid-Western Regional hospital, Surkhet on Human Resource Management. The objective of the study was to describe the status of human resources of the hospital and to critically analyse the various aspects of HRH management.

Methods: For this, methods like key informant interviews (medical superintendent, chairperson of hospital development board), observation, literature review discussions and survey were used. The tools used were Interview guidelines, questionnaires and checklists. A sample survey size 32 among 89 health workers (HW) was chosen.

Results: Among the HWs interviewed only 47.8% were satisfied with the current facilities. Similarly, 81% of the HWs responded that they had an opportunity for career development. Among them about half (42.3%) replied that they had career development opportunity by day to day clinical exposure leading to clinical update. Similarly, about one-third replied that they received trainings while others replied professional development, private practice and promotion led to their career development. It was found that higher level staff like consultants and MOs were not sure of career development in comparison to lower level staff like HA, AHW. Medical Officers who were placed temporarily on bond with MOE were found to be worried about their future .They were pretty sure that rural postings will not help them in obtaining residency, so they were busy in private practice so that they could afford themselves higher education and this has hampered health service delivery in the mid western regional hospital. However, those who are recruited through public service commission get ample of opportunities for MD/MS study, so there is a craze for government service but the number is quite low. Higher level staff faces difficulty of technology and work environment because they have to almost totally depend on clinical skills /clinical knowledge and they have a fear that they might forget all advanced techniques and technologies learnt during their trainings. There is a lack of clear government scheme or policy for higher education and training to HWs working in Peripheral health institutions, so they seem to be frustrated. It is known that they would leave the job any time if they got a better opportunity.

Conclusions: Thus to encourage the HWs to work in peripheral health institution in an efficient way, there should be schemes/provisions for higher education, advanced training, in-service training, etc. Last but not the least, there should be regular supply of equipment, good working environment, regular supervision, monitoring and feedback so that they can be encouraged to work with effectiveness.

41


Medical Students’ Characteristics as Predictors of Career Practice Location: Retrospective Cohort Study Tracking Graduates of Nepal’s First Medical

College

Mark Zimmerman1, Rabina Shakya 1, Bharat M Pokhrel 2, Nir Eyal3, Basista P Rijal2, Ratindra

N Shrestha2, Arun Sayami2 1Nick Simons Institute, Box 8975, EPC 1813, Kathmandu, Nepal; 2Institute of Medicine, Kathmandu, Nepal; 3Harvard Medical School, Boston, Massachusetts Correspondence: Rabina Shakya, [email protected] Background: Doctor migration from the low to high-income countries and from rural to urban areas is extensive, but evidence is mostly limited to high income countries. This paper demonstrates an association between several pre-graduation factors, which could be used to guide medical school entrance criteria. Doctors tend to migrate from medically less well served areas to better served areas. This paradoxical flow occurs over a continuum that includes internal migration (often from rural to urban areas) and external migration (from low income to high income countries). Both result in adverse outcomes for patients in the areas of origin. In recent policy documents, the World Health Organization and others have issued calls to “build the evidence base” on retention of healthcare workers in underserved areas. The main objective of the study was to determine, in one low income country (Nepal), which characteristics of medical students are associated with graduate doctors staying to practise in the country or in its rural areas. Methods: An observational cohort study was conducted to determine which characteristics of medical student predicted location of practice in underserved areas, we analysed seven factors. We chose to study place of birth, place of high school, and sex to test the conclusions of previous studies done in high income countries. We also included type of pre-medical education because of the undocumented observation in Nepal that more doctors from a paramedical background seemed to stay in Nepal. We included year of graduation in the analysis to account for historical trends. Finally, we included final academic score and age at matriculation because these were potential confounders. A total of 710 graduate doctors were selected from the first 22 classes (1983-2004) of Nepal’s first medical college, the Institute of Medicine. Results: 710 (97.7%) of the 727 graduates were located: 193 (27.2%) were working in Nepal in districts outside the capital city Kathmandu, 261 (36.8%) were working in Kathmandu, and 256 (36.1%) were working in foreign countries. Of 256 working abroad, 188 (73%) were in the United States. Students from later graduating classes were more likely to be working in foreign countries. Those with pre-medical education as paramedics were twice as likely to be working in Nepal and 3.5 times as likely to be in rural Nepal, compared with students with a college science background. Students who were academically in the lower third of their medical school class were twice as likely to be working in rural Nepal as those from the upper third. In a regression analysis adjusting for all variables, paramedical background (odds ratio 4.4, 95% confidence interval 1.7 to 11.6) was independently associated with a doctor remaining in Nepal. Rural birthplace (odds ratio 3.8,

42


1.3 to 11.5) and older age at matriculation (1.1, 1.0 to 1.2) were each independently associated with a doctor working in rural Nepal. Conclusions: A cluster of medical students’ characteristics, including paramedical background, rural birthplace, and lower academic rank, was associated with a doctor remaining in Nepal and with working outside the capital city of Kathmandu. Policy makers in medical education who are committed to producing doctors for underserved areas of their country could use this evidence to revise their entrance criteria for medical school.

43


THEME: MOTIVATION, PERFORMANCE AND ACCOUNTABILITY OF HEALTH WORKERS

Motivation and Retention of Health Workers in Nepal

Jagadishwor Ghimire1, Rajendra Gupta1, Raj Kumar Mahato1, Arjun Kumal1, Niranjan Thapa1, Ashmita Hada1, Deepak Kumar Bishwakarma1

1Save the Children Country office Nepal

Correspondence: Jagadishwor Ghimire, [email protected]

Background: Human resource for health (HRH) plays an important role in improving the health of people and for the smooth functioning of the health system. The shortage of HRH is major problem facing in Nepal, as it is one of the 59 countries having critical shortage of HRH. The absence of health workers, low level of motivation, and proper distribution of health workers, especially the geographical and urban and rural further compounded the problems in the country. The main purpose of the study was to find out the factors responsible for motivation and retention of human resource for health working in public sectors.

Methods: A Cross sectional study using both qualitative and quantitative methods was conducted in Kathmandu, Siraha, Bardiya, and Doti districts during September, 2012 to February, 2013. The health facilities were selected proportionately representing all the Illaka and then simple random sampling was done to select the individual facilities. Data was collected using the questionnaires, client exit interview, key informant interview, in-depth interview and the focus group discussion. The collected quantitative data was entered in MS Excel and SPSS with double entry system and analyzed using SPSS. Ethical approval was also taken from the Nepal Health Research Council (NHRC).

Results: The findings revealed that majority of health workers were from the age between 20 to 40 years (55%) with the average age of 38 years (SD: 10.6). The result revealed that 45% of health workers were Brahmin and chetri followed by terai caste (30%). More than half (55%) of the health workers were satisfied from their current job and their financial benefits.

The results revealed that the age, education and the service duration were statistically highly significant for the motivation of health workers. The health professionals having bachelor and above level of education were 2.6 times (CI: 1.414-4.660; P: 0.002) more motivated than the health workers having proficiency certificate or less. Health workers with service duration of less or equal to 20 years were 2 times more motivated (CI: 1.193-3.306; P: 0.008).

Different factors affect the motivation of health workers. The study also revealed that financial reward (OR: 4.706; CI: 2.961-7.478; P: 0.000) was significantly associated with the motivation of the health workers. The good working environment and the opportunity for capacity development were also statistically significant. The good working environment motivates health workers by nearly 2 times (CI: 1.507-3.648; P: 0.000). Similarly, the opportunity for capacity development also motivates health workers by 5 times (CI: 3.344-8.840; P: 0.000).

The study also suggests that different factors can play important role for de-motivating health workers at their work place. Low remuneration (OR: 3.215; CI: 2.049-5.045; P: 0.000), the limited opportunity for capacity development (OR: 4.269; CI: 2.672-6.821; P: 0.000), poor working environment (OR: 4.062; CI: 2.528-6.526; P: 0.000), no institutional

44


recognition of their performance (OR: 2.157; CI: 1.389-3.350; P: 0.001), domination by political parties (OR: 2.752 ; CI: 1.754-4.320; P: 0.000) were the major de-motivating factors for the health workers.

The factor analysis of the retention factors revealed that cohesiveness among the staff (0.733), salary and other financial benefits (0.737) and external and internal environment (0.795) of the working institutions out of eight factors were statistically significant. The most influential factor up to this analysis was the internal and external environment for the retention of health workers at their workplace.

Conclusions and Recommendations: Motivation and retention of the health workers are the important factors for the smooth functioning of the health intuitions, increase access to quality health services and achieve the positive health of people. From the findings we can conclude that though, salary and other financial benefits matters for health workers for their performance, there are also other factors playing a crucial role for motivation and retention of health workers, which should be considered during the planning and policy formulation stages. MoHP, should also give emphasis on strengthening the working environment at the health institutions for better motivation and retention of health workers.

Health Workforce Performance and Accountability

Chandika Shrestha1, Amod K Poudyal2, Khem B Karki3 1Medical Emergency Relief International, Nepal 2 Institute of Medicine, Tribhuvan University, Nepal 3Society for Local Integrated Development, Nepal Correspondence: Chandika Shrestha, [email protected] Introduction: The performance of health workers plays a crucial role in the improvement of health outcomes, due to its impact on accessibility to health services and appropriateness of care provided to service users. Despite its key impact on health outcomes, there is limited evidence on the performance of health workers and effective strategies in Nepal. This report therefore provides insight into health workforce performance in Nepal, looking at the four dimensions of health workforce performance: availability, competency, responsiveness and productivity. Methods: A descriptive study, using mix methods, self-administered interview with 747 health workers from 375 institutions of 15 districts was carried out. In-depth qualitative interviews and group discussions with service providers and users at different levels were conducted. SPSS was used for statistical analysis Results: Despite the fact that policies are in place to ensure the availability of health workers, less than half of health workers were present in their work place at the time of survey. Reasons for absenteeism among Health Workers (HWs) included deputation, training, leave and transfer. The situation was particularly difficult in remote rural areas particularly the western mountain regions. Local governments chose to address the issue by recruiting temporary staff at the local level, predominantly from the same area. In comparison to permanent staff, the short term

45


suitable solution does not ensure that staff are sufficiently supported with the correct salary and benefits package or career structure. A high percentage of health workers felt they were unable to work to the expected standard due to lack of training and performance management. Trained staff do not meet required competency levels and there is limited management training which has affected the quality of district and facility management. Health workers are often not provided with the job description or outdated job descriptions with poorly defined responsibilities. In addition to these constraints over half the health staff stated they had insufficient equipment and medical supplies in their facilities. This lack of support affected services that could be provided, the confidentiality of service and communication between health staff and patients. In turn this affected the sense of pride in health workers and their connection with the community. There are limited resources for communities to address shortfalls in clinical care. Accountability systems are weak; and district and village development committees have limited budgets and authority. Conclusion: A more effective recruitment system and greater investment in permanent positions is required, as well as a more decentralised system to support improved information on staff availability and more appropriate deployments. The training curricula needs to be revised and updated, with a greater emphasis on broader public health skills to support primary health workers to undertake greater clinical roles in the absence of doctors in remote areas. A greater emphasis on health management is also required. Civil Society Organisations can work with local authorities to ensure appropriate accountability and complaint systems, which are essential for ensuring improved performance in the health workforce.

Working Conditions of Health Workforce in Nepal

Manju Neupane1, Chandika Shrestha2 and Khem Bahadur Karki1

1 Society for Local Integrated Development Nepal

2 Medical Emergency Relief International (Merlin), Nepal

Correspondence: Manju Neupane, [email protected] , [email protected]

Introduction: Conducive working condition for health workforce is essential for the quality delivery of the health services to the people. This study was aimed at exploring working conditions of health workforce in relation to income, incentives, work supplies, equipment, issues on safety and security and the role of local authorities/community.

Methods: A cross-sectional descriptive study, using both qualitative and quantitative research methods was conducted in 15 districts of Nepal with eco-developmental representation to obtain comprehensive information on human resources for health status in Nepal. A total of 256 health institutions were observed.

46


Findings: Findings from focused group discussion showed that the salaries provided do not match with the expectations of overall health workforce. . There is no clarity in government policies about non- financial incentives provided to the health workforce. A clear gap also exists between the entitlements stated in government policies and availability and access to these services in the real ground.

The provision of financial and non- financial incentives are being hampered by poor monitoring systems, leading to poor motivation and disputes among staff. This also undermines attempts to improve maternal and child health. These issues were highlighted in focused group discussions, where female community health volunteers expressed their dissatisfaction with the irregular provision of non financial incentives and health workforce involved in deliveries stated inconsistencies in the process of receiving maternal allowance.

Disparities were found in the working condition of health workforce like, lack of career development opportunities and access to travel allowance between Mountain and Terai Regions. Career opportunity and private practice opportunities are higher in Terai (33.4% & 56% respectively) than those in the Mountain region (12.7% and 17% respectively).

Poor provision of infrastructure, equipment, supplies in the health facilities were found to be an issue, particularly, in the rural areas, contributing to low level of motivation and poor staff availability. Conflict between service providers and service users was also a demotivating factor.

Perception of security was influenced by local factors like conflict with service users within the institution and by the political factors which is a barrier to effective human resources for health management in Terai. The perception of security based on the cadre of health workforce is the highest among technicians (84%) and lowest among doctors (70%).

Conclusion and Recommendations: Poor working conditions compromises health workforce supply, retention and quality of care. Thus, recommendations focus on improvements in the management of human resources, equipment, supplies and quality monitoring for incentive-based systems especially for maternal and child health outcomes.

Job Satisfaction of Health Workers Working at Peripheral Health Institutions in Siraha District

Sumit Karn 1, Dr. Surya Raj Niraula 2

1 Save the Children, Suaahara/Nutrition Section, Child Health Division

2 School of Public Health and Community Medicine, BPKIHS, Dharan

Correspondence: Sumit Karn, [email protected]

Background: Human resource is the most important labor intensive component in organizations of health services. The World Health Report 2006 identified among others, low morale and motivation of health workers as one of the main constraints in the delivery of interventions aimed at achieving the health related MDGs. Given that most emphasis is on prevention and promotion of health, Government of Nepal has committed to deploying technically competent and socially responsible health workers to provide quality health care to all the population particularly those living in rural areas. In Nepal, 80 percent of the

47


population seek health care services from public health institutions and the quality, accessibility, utilization, efficacy and efficiency of the services at those institutions largely depend on the performance of service providers which is closely linked with their job satisfaction.

Objectives: The study aims to assess the job satisfaction of the health workers working in the sub-health posts and to identify the major factors associated with it.

Methods: This exploratory study used both qualitative as well as quantitative methods. A self-administered questionnaire using likert scale was distributed among health workers at sub-health posts. From the list of total sub-health posts, 30 percent i.e. 28 sub-health posts were sampled using a simple random method. 47 sub-health posts were selected. All health personnel working at the sub-health post, namely auxiliary health workers, village health workers and maternal and child health workers, were the respondents of the study. However, due to absence of few health workers, only 109 health workers were included. The questionnaire comprised of 19 different questions covering a range of factors of job satisfaction. A total of 5 in-depth interviews were also conducted with key people in the district to know the organizational level factors to complement the quantitative findings.

Results: Majority (64%) of the health workers were male, with the average age of 38 years. Most (80%) were from the same district, almost two-thirds (63.1%) of the health workers were reported satisfaction in the quantitative measurement. However, the qualitative research findings revealed that majority of the health workers were dissatisfied with their jobs. Poor working conditions, unpredictable transfer, low salary and political instability were the main factors which lead to dissatisfaction; while respect from community people, love for work, appreciation for work from the patients and patient’s satisfaction were reported as the factors contributing towards job satisfaction. Majority of the health workers considered effective supervision and quality training as useful management tools to improve personal as well as organizational performance.

Conclusions: Most of the factors that led to dissatisfaction among health workers were found to be linked with the health system and human resource management issues. Mitigating measures were therefore necessary and could make a difference to job satisfaction of the health workers at the peripheral health facilities.

Patient Satisfaction with Nursing Care in Different Hospitals of Kathmandu Valley

Gita Dhakal Chalise1

1Head of Nursing Department, National Academy for Medical Sciences, Purano Baneswar, Kathmandu Correspondence: Gita Dhakal Chalise, [email protected]

Background: After National Health Policy (1991), a large number of health institutions were established by the public and private sector to train different cadre of health care professionals. Similarly a large number of private hospitals have also been established to expand secondary and tertiary care in urban areas. Till now, there are 44 functional Private Hospitals and 5 Government/semi-government hospitals within the Kathmandu Valley.

48


Similarly 3 medical colleges and 49 nursing colleges within Kathmandu valley are producing a large number of medical doctors and nurses. Considering today's highly competitive healthcare environment, these institutions should realize the need to focus on service quality as a means to improve their competitive position. Curing and caring are the fundamental components of health care services; the doctors focus on the curing issues whereas the nurses take responsibility of caring the patients. Nursing care is one of the major components of health care services. Patient care is not considered to be high quality unless the patient is satisfied. During hospitalization, patient satisfaction represents a balance between the patient’s perception and expectation of their nursing care.

Objectives: The objective of the study was to assess the level of patient satisfaction with nursing care in 2 different hospitals of Kathmandu valley.

Methods: A cross sectional descriptive cum exploratory study was carried out at two different hospitals of Kathmandu Valley, one was Private Hospital and the other was Community Hospital. A total of 50 inpatients (admitted for more than a week), 25 from each hospital, were selected by using non-probability purposive sampling technique. To measure patient satisfaction, SERVQUAL instrument was used which is a

Multi-item scale used to assess patient satisfaction with nursing care. Questions were asked on five dimensions of SERVQUAL and categorized as satisfied and unsatisfied. Those five dimensions were: tangibility, reliability, responsiveness, assurance and empathy. In each dimensions, different questions were asked with patients. The data were analyzed by using SPSS version 16 for windows.

Results: The study result shows that more than 70% of patients were satisfied with most of the tangibility dimension (cleanliness, odor free, adequate equipment and supplies and comfort) in both hospitals. But they were unsatisfied (32%) with safe water supply and canteen facility in these hospitals. In both hospitals, more than 90% patients were satisfied in reliability dimension (quick service, showing interest in solving patient's problems, giving accurate and reliable information). In responsiveness dimension (willing to help patient, willing to answer questions, immediately responding to patient discomfort and visit at appropriate time), more than 80% patients were satisfied with nursing care in both hospitals and the rest were dissatisfied. 88% of patients were satisfied with assurance dimension (have knowledge on patient care, clear explanation, make patient feel comfortable and secure and discharge teaching). In empathy dimension (pleasant tone of voice, empathetic, feeling of ownership and giving personal attention), around 80% patients were satisfied with nurses but in the same dimension, only half of the patient were satisfied with nurse's communication with them.

Conclusion: Still 30% patients were unsatisfied with tangibility factors as hospitals were not able to provide clean and pleasant odor in their room and comfortable bed, blanket, safe water supply and canteen facility to them. Similarly more than half of the patients were unsatisfied with nurse's communication with them. Communication problem was found as the prime factor for patient dissatisfaction with nursing care in this study.

49


THEME: HRH POLICY AND MANAGEMENT

HRH Gap Analysis in Relation to National Objectives and Priorities

Raj Kumar Mahato1, Jagadishwor Ghimire1, Rajendra Gupta1, Niranjan Thapa1, Arjun Kumal1, Ashmita Hada1, Dr. Bhimsen Devekota2, Dr. Rajendra Kumar B.C.2

1Save the Childern; 2 Development Resource Centre

Correspondence: Raj Kumar Mahato, [email protected]

Background: Human Resources play a critical role to ensure access to quality health services. While demand and supply sides have major influence on Human Resources for Health (HRH) situation in Nepal, few global initiatives such as the Millennium Development Goals and major national policies, plans and political situation also have significant influence. Nepal government acknowledged HRH related issues since the first long term plan in 1974. The national health policy 1991 and the eighth five year plan (1992-97) are fewer examples of earlier efforts made to produce trained health workers by enhancing institutional capacity and mobilizing public and private sectors. The government has developed acts and strategic plans to support of HRH in Nepal. The Civil Service Act 1993 and Health Service Act 1997 are two acts providing clarity on the rules for HRH management including their recruitment and transfer and priority to locate staff in their own districts. Moreover, the government has developed long term strategies as well as short term plans to improve the HRH situation. The second long term Health Plan for 1997 to 2017 and HRH Strategic Plan 2003 to 2017 lays emphasis on providing technically competent and socially responsible health personnel. Similarly, NHSP I 2004-2010 sets the standard of appropriate... NHSP II 2010-2015 outlined 16 various actions to be carried out and includes a scientific and robust projection of human resources. The study was conducted to analyse the HRH gap in relation to HRH objectives, guidelines and priorities.

Methods: The study was conducted through literature review, focussed group discussions at different levels, Key informant interviews with selected policy makers, district level stakeholders and HRH Alliance members.

Results: The HRH long term plan and Strategic Plans have been developed, endorsed and published to address a few long standing HRH issues like shortages of HRH as a result of imbalance between supply and demand, mal-distribution of staff in remote and rural areas, poor staff performance including productivity. The approved plan has not been rolled out effectively as it does not have adequate level of ownership as there werelack of new activities. Most of the policy and plans do not address the issues of absenteeism, retention, migration of HRH and Diaspora engagement in Nepal. The key strategic plans and documents have mentioned HuRIS and expected to provide clear information on HRH but HuRIS is not inclusive to give full picture as the system does not cover all HRH of the country. The discriminatory distribution of HRH still exists widely, including the provision of minimum years of performance before the transfer exists in the Health Services Act (1997). But, the provision of minimum years of service to be eligible for the next transfer is not followed properly. The three year interim plan (2007-2010) and GESI strategy 2009 have been developed to promote access of Dalits and other excluded groups to quality health services but low participation of Dalits and other highly excluded groups in the health workforce can easily be seen. Quality Assurance for raising the awareness of service users on their rights and responsibilities is one of MoHP’s policies but there is clear gap.

50


There are also policies and documents on health training. The revised National Health Training Strategy 2004 focuses on development and management of HRH for quality health services. The SBA In-service Training Strategy (2006-2012) aims to provide competency-based in-service training on SBA to all eligible current and newly recruited staff. NHTC conducted trainings are yet to be accredited and certificated. Challenges to produce professional trainers in disciplines such as public health, nursing, clinical health education etc is still there. Most of the training is ‘supply driven’. There is a large number of academic institutions to produce different cadres of health workforce. But most of them are have poor and inadequately equipped teaching infrastructure. The review revealed that performance based recognition has started recently. But, punishment is not observed in health system except transfer and clarifications in writing.

Conclusions and Recommendations: Health workforce is extremely important resource of the health system. They should be treated as are assets to the system. There is lack of implementation of the plan and policies developed in the past. The HRH planning including pre-service and in-service training has to be an integral element of overall planning as envisioned in NHSP II. There is a need to increase participation in health workforce from Dalits and other excluded groups. As a training and quality monitoring institution, the capacity of NHTC is not fully utilized and developed. The options might be an autonomous National Health Training Academy. As there is lack of accountability, efforts should focus in promoting culture of accountability among HRH at all levels. A policy to develop a pool of potential professional staff who can provide and / fill in the gap by taking leadership both in technical and administrative functions at district to national levels may be an option. The information in HuRIS should be comprehensive, reliable and up-to-date with information of all health workers not only related to recruitment, retention, transfer, training but also their performance.

Human Resources for Health (HRH) Management from Central to District Level in Nepal

Anant K Nepal1, Ajit Acharya2, Khem B Karki2

1 Medical Emergency Relief International, Nepal 2 Society for Local Integrated Development, Nepal Correspondence: Anant Nepal, [email protected] Introduction: Nepal faces considerable challenges in Human Resources for Health (HRH) management, which is characterised by top-down decision-making despite amendments to policy emphasising the empowerment of local government. The research examines the main gaps in the human resources management system in the public health sector and makes recommendations for viable mechanisms to strengthen the system. Methods: A cross-sectional descriptive study was conducted using mixed methods with observation checklist. Fifteen districts representing eco-developmental regions of Nepal were selected using multi-stage cluster sampling method. Out of 404 sample, 747 health workforce from 375 health institutions were interviewed using the Probability Proportionate to Size method as per World Health Organisation (WHO) guideline. In-

51


depth qualitative interviews and focus group discussions with service providers and users at different levels were conducted. Statistical Package for the Social Sciences (SPSS) was used for statistical analysis. Results: The recruitment process is complex, requiring multiple levels of authorisation. The combination of a lengthy legal selection process and administrative delays lead to posts being vacant for a long time, and results in numerous positions (30.57%) being filled on a temporary or daily wage basis at local level. Furthermore, there are contradictions between the Health and Civil Service Acts which has resulted in the cancellation of advertisements for specific jobs. The transfer system, in-service training, rewards and punishment systems are criticised as unsystematic, highly centralised and politicised, with allegations of nepotism and corruption. Ineligible transfers are taking place, resulting in the irregular and unplanned nature of transfers. There is a mismanagement of candidate selection for in-service training, with 61 percent of respondents claiming that this process is impartial and biased. The system to upgrade a particular post, based on the duration of service period, is in place. However, the employee must work in the same position with same responsibilities. Health Workers are dissatisfied with these systems, which they claim are based on political influence rather than policy. Seventy three percent of respondents perceived lack of transparency and consistency in selection of candidates for the training. Centralised decision-making and pertinent functional issues relating to health services decentralisation aren’t well addressed. The pertinent issues related to the decentralisation of the health service delivery system that needs to be addressed: top down planning and management, lack of coordination, lack of resources and weak institutional capacity. There are administrative constraints in the function and validation of the Human Resources Information System (HuRIS). Lack of technical competencies due to migration of trained personnel, unwillingness of staff to update the records on time and under/over reporting, are common problems within the system. Despite training being given to all 75 districts, the information is most commonly being updated at the central level. Conclusion: Although Health legislation and policy is well developed and unbiased, the perception of nepotism in transfer and training leads to inequitable systems. Decentralisation is only partial and thus largely ineffective, and the information system is cumbersome and not utilised effectively.

52


Health Governance at Local Level from Human Resource for Health Perspectives: The Case of Nepal

Bhimsen Devkota1, Anju Devkota1 , Jagadishwor Ghimire 2, Rajendra Gupta2, Raj Kumar Mahato2

1 Development Resource Centre, Kathmandu, Nepal 2 Save the Children, Sinamangal, Kathmandu, Nepal Correspondence: Dr. Bhimsen Devekota, [email protected] Background: Good governance is recognized as one of the six building blocks of an effective health system. It is a catalyst for strengthening health services delivery. However the issue of governance and its influence in addressing the Human Resources for Health (HRH) crisis has been overlooked in Nepal. The governance infrastructure, its status and challenges at the grassroots and implementation level in relation to HRH at the district, sub-district and community level is not known. Objective: To explore the situation of health governance at the local level in relation to the improved health care, changed power structure and accountability mechanisms and initiatives of the government to address the HRH challenges including gender and social inclusion. Methods: Ninety health facilities from Siraha, Bardiya and Doti districts were included in the study including district hospital, primary health care centre, health posts, sub-health posts, district Aurvedic health centre and Aurvedic dispensaries. In addition, focus group discussions (N=36) with different groups and key informants interviews (33 VDC Secretaries and 76 Health Facility Management Committees and 9 central level) were conducted. Results: Only 54% of the health facilities have properly displayed the office signboard and 36% of them are without signboard. Despite the government’s clear direction to display citizen charter, 33% of health facilities have not done this. Information display on free health services was in 40% health facilities. Only 27% health facilities have displayed information about maternity incentive properly and 61% have not. In total 58% health facilities have not displayed names of women receiving Aama benefits. 72 out of 90 health facilities have not displayed Social Audit reports. Similarly, 89% of the health facilities have not placed complaint box for the clients. The initiative of decentralized HR management has promoted ownership at the local level and there are examples of resource sharing with VDCs and DDCs to equip health posts, recruit health workers, improve and add services including laboratory for blood and urine tests and to support some. Staff retention has been reported well though it does not apply in case of the medical doctors. Rule of law in terms of human resource recruitment and transfer, promotion, and training were not fully implemented and were lenient in the upper level. Nepotism and power exercise was frequently reported as a hindrance in implementing the gender and social inclusion policy fully. Post training follow- up mechanism seems lacking.

53


Conclusion: Transparency, one important principle of governance, does not seem implemented fully at the district level. The system of social audit was found to be very poor in all of the three districts and it was not displayed well. Though the concept of gender and social inclusion has been incorporated in the health sector, it is yet to be fully implemented at the local and district level. Key words: Health governance, human resources for health, Nepal

Human Resource for Health in Nepal: Analysis of Policies and Practices

Britain Nepal Medical Trust Correspondence: Dr. Poonam Risal, [email protected] Background: Human Resource for Health is a global crisis. Although Nepal has made a remarkable progress in meeting most of its Millennium Development Goal, the growing inequality in health indicator among the population and shortage of health workers are still a major concern. The problem is further exacerbated by the unequal distribution of available health workforce; inappropriate skill mix; training, motivation and deployment, and wages and incentives. Objectives: To enhance understanding on the state of HRH policy and situation in the country and to identify the gaps in implementation. Methods: The methodology primarily consisted of review of the existing documents under Ministry of Health and Population. In addition, Key Informants Interview (KII) and data on HRH was collected from ten districts (Achham, Bajura, Kalikot, Panchthar, Nawalparasi, Sindhupalchok, Dang, Kailali, Kapilvastu and Doti). Results: Health Services Act 1979 and Civil Service Act are the major legal documents governing the employment of health sector staff. Now, in absence of other suitable mechanism, many staffs are employed under Procurement Act. Not all staffs working in MOHP are governed by a single act. Unequal distribution of available health workforce, inappropriate skill mix, training, motivation and deployment, and wages and incentives are among the major concern in Human Resource for Health management. The existing skills mix revealed that only 4 percent of the total health care providers are doctors, 12 percent nurses excluding ANMs, 47 percent paramedics, 0.92 percent public health officers, and 3.1 percent traditional health care providers. However, the skill mix at the district level appeared relatively better in terms of different category of staff except the doctors. Facility survey (2009) indicated a better picture of staffing at HP and SHP level than at Hospitals and PHC level. The health act along with other acts (e.g. LSGA 1998) has allowed for local recruitment of human resources. Among the sources that employ the local staff in the health institutions, VDC and HFOMC together employ over 70% of staff. Absenteeism from work was widely reported in the study districts. The most common reasons for absenteeism were secondment and training. Transfer has been a major reason for staff turnover. The reasons for seeking transfer for almost all staffs were cited as the desire to be in hometown or to be with family (91%). Though there is an extensive performance appraisal system in place, the use of performance appraisal is very limited. Budget analysis also indicated that other than salary line items, the budget in other HR related items has

54


sharp increase from previous years but there is no explanation on such sharp and sudden rise from the year 2008/09 to 2009/10. Conclusion: Nepal has made remarkable progress in meeting the Millennium Development Goal, however, Human Resources for Health management is a challenge. Current approaches indicate that there are number of strength and weaknesses. Therefore, there is a need to review, implement and strengthen policy for better Human Resources towards greater impact and quality of health service delivery.

Human Resource for Health: Views of Public Service Commission

Khagendra Prasad Subedi1 1Senior Psychologist, Public Service Commission

Correspondence: Khagendra Prasad Subedi

Background: Public Service Commission (PSC) was established in Nepal on 15 June 1951 A.D. The Commission is involved in selecting meritorious candidates required by Government of Nepal for various vacant posts of the civil service. The continuity of PSC has never been hindered since its establishment. Present Constitution of Nepal has designated Public Service Commission as an independent constitutional body.

Functions, Duties and Powers: The functions, duties and powers of Public Service Commission are as follows:

1. To conduct examinations for the selection of suitable candidates to be appointed to various civil service posts.

2. Permanent appointment to any position in the civil service which carries the benefit of pension shall not be made except in consultation with the PSC.

3. Government of Nepal is required to consult the PSC on the following subjects:

a. matters concerning the laws relating to the conditions of civil service;

b. the general principles to be followed in the course of appointment to, promotion and departmental action concerning the civil service or positions;

c. matters concerning the suitability of any candidate for appointment to a civil service position for a period more than six months;

d. matters concerning the suitability of any candidate for transfer or promotion from one service to another within the civil service or any other government service to the civil service;

e. matters concerning the permanent transfer or promotion of any employee, working in any position of an organization which is not required to consult with the Commission on matters of appointment, to any position for which consultation with the Commission is required;

f. Matters relating to departmental actions proposed against any civil servant.

4. Subject to the Constitution other functions, duties and working procedures of the PSC shall be as regulated by law.

55


5. Every year, the Public Service Commission shall submit annual report on the works it has performed to the President. The President shall arrange to submit the report to Legislature-Parliament through the Prime Minister.

Process of Selection: The Public Service Commission conducts examinations for selection of candidates as per the Public Service Commission (Procedure) Act, 2066 B.S. using one or more methods of selection as follows:

a. Open competitive written examination,

b. Open competitive practical examination,

c. Interview and,

d. Any other methods adopted by the Commission.

The Commission has its annual calendar of operation which consists of activities that incorporate all the detail phases of the selection process. In order to carry out selection process, the Commission publishes vacancy announcement for the candidates concerned every Wednesday in the "Gorkhapatra" daily as well as in its weekly bulletin.

In order to maintain fairness and impartiality in the selection, the commission has adopted a system of "multi-blindness" in which setting and moderation of questions, checking of answer sheets, conducting of interviews as well as result of written examinations and interviews are carried out in a manner that officials involved are kept in anonymity to each other.

The PSC maintains a pool of experts and specialists for the purpose of selection. They are assigned to the specific selection tasks in a confidential manner. The PSC has also initiated the process of screening for certain posts where numbers of candidates are high. The candidates have to get through the preliminary examination in order to appear in the main examination.

Role of Public Service Commission regarding the human resources for health service: Rules and regulations regarding permanent, temporary and contracts are set out in the Civil Service Act 1993 and the Nepal Health Service Act 1997. The Public Service Commission (PSC) is responsible for permanent recruitment; however, for not more than six months period, it can provide permission to the concerning authorities of MOHP for recruitment in temporary or contract basis.

The specific inclusion quotas for women, different ethnic groups, and disadvantaged groups were included in the Civil Service Act for the last six years which was lacking in the Health Service Act. However, recent amendments in the said Act have addressed the recruitment problem of Ministry of Health and Population for inclusive groups. It gives space to the provision of specific inclusion of quota for women and socially and economically disadvantaged groups. On the basis of this amendment, Public Service Commission has published special exam schedule and announced open competition for different positions of the health sector.

Problems and Challenges

Amendment of health act took a long time due to which open competition exams were delayed.

PSC does not receive all vacant posts requisition on time.

56


Retention of qualified health experts in general and absenteeism of staffs in the field in particular.

Non availability of sufficient health experts from the view point of exam

Recommendations

PSC has introduced OMR system exam for non-gazetted technical posts, by which exams and its results can be published in a shortened time. This may lead to fulfilment of vacant posts twice a year unlike once a year in present condition.

Address the retention problem of health workers. Human resource planning should be the major agenda. Since health is a sensitive sector, position creation and position registration

processes should be shortened. Vacancy information should be shared with PSC on time. Training and experience included in qualification has raised issue which has affected

the HR recruitment. Therefore MOHP, PSC, and MOGA should sit for resolving it. The ethics/code of conduct regarding the health personnel must be strictly

implemented and monitored (e.g. over 30 days absence without notice)

Conclusions:

PSC does not receive all vacant posts requisition on time. Non availability of sufficient health experts from the view point of exam. Since health is a sensitive sector, position creation and position registration

processes should be shortened. Vacancy information should be shared with PSC on time. Training and experience included in qualification has become an issue which has

affected the HR recruitment. Therefore MOHP, PSC, and MOGA should sit for resolving it.

57


THEME: ROLE OF PRIVATE SECTOR INCLUDING PUBLIC PRIVATE PARTNERSHIP FOR

HRH

Role of Civil Society in Human Resources for Health Management in Nepal

Bhuwan Baral1, Bidhan Acharya2, Khem Karki1 and Raju Prajapati1

1Society for Local Integrated Development NepaL (SOLID Nepal), Satdobato, Lalitpur 2 Central Department of Population Studies, TU, Kirtipur

Correspondence: Bhuwan Baral, [email protected]

Introduction: Current national health policies and strategies of Nepal illustrate the government’s commitment to involving Civil Society Organisations (CSOs) in improving Human Resources for Health (HRH) through the decentralisation of health service delivery and the handover of facilities to the Health Facility Operation and Management Committee (HFOMC).

Objective: To analyse the engagement of civil societies and their role in HRH for effective healthcare service delivery in Nepal.

Methods: A cross-sectional descriptive study was conducted using both quantitative and qualitative methods. Fifteen districts representing eco-developmental regions of Nepal were selected using multi-stage cluster sampling method. Out of 404 sample health institutions, 747 health workforce from 375 health institutions were interviewed (<10% non-response rate) using the probability proportionate to size method as per WHO guidelines.

Findings: Qualitative data indicated a gap on policy implementation, health sector decentralization and CSOs involvement to improve HRH. Nearly 75 percent respondents had opined that the political parties were supporting the health institutions in the grassroots. Health workers have observed involvement of CSOs in planning, implementation and monitoring of the health institutions. It was found that the support from the CSO was better in Hill (54.9%) compared to Tarai (46.9%) and Mountain (46.7%). The support was significantly different between rural and urban [p <0.05, CI 95%]. Mean Index score of effectiveness of CSOs was found highest in Hills (0.3036) followed by Mountains (0.2669) and Tarai (0.2589). Eighty five percent of health workers felt secured where CSOs effectiveness was high. There was a positive correlation between the effectiveness of CSOs and the feeling of security by health workers. Similar to the feeling of security, a high percentage of health workers felt high social prestige in areas with a high effectiveness of CSOs. Feeling of safety was also found interlinked with retention of HRH in working place. While analysing the manifestos of 9 major political parties, only 5 of them have mentioned policy statements on HRH production, distribution and implementation whereas only one party has highlighted strategies with peoples’ participation.

Conclusion and Policy Implications: The roles of civil society in HRH management still need to be recognised and well documented in policy documents to seek their active participation in formulation and implementation of policies, strategies and planning related to HRH for effective and quality healthcare services in Nepal.

58


Constructive dialogue, planning and mobilisation around the health workforce to broaden the extent of social determinants of health are needed in collaboration with GOs, I/NGOs and private sector should be ensured. The district level governance should establish an effective coordination between DDC and DPHO, it should utilise local media and use efforts to enhance the involvement of civil society in health programmes. It should also identify the areas that are unsecured and with low social prestige for HRH within district and periodically counsel the CSOs for making better environment.

Public Private Mix Collaboration Model in Enhancing Tuberculosis Case Detection: An Experiences from Eastern Nepal

Dr. Deepak K Yadav1, Mr Dhurb Uraw1, Mr Ramdev Chaudhary1, Dr. Rajendra Pant1, Prof. BP Das1

1 Dept. of Health Management, School of Public Health & Community Medicine, BP Koirala Institute of Health Sciences, Dharan

Correspondence: Dr Deepak K Yadav, [email protected]

Background: Tuberculosis still remains a major public health problem in Nepal. Directly Observed Treatment Short course (DOTS) based TB services are available in all 75 districts of the country since 2001. TB patients are seeking care from a wide variety of health care providers especially in urban & slum areas. The treatment seeking from private sector is as high as 69 percent in urban setting. These providers may not be properly trained or made to follow the recommended DOTS strategy for TB, resulting in an increased number of recurrence of TB and high chances of drug resistance. In order to address this issue, Public Private Mix (PPM) initiative emerged as a strategy to involve all relevant health providers in TB control.

Objective: To enhance the TB case detection through Public Private Mix (PPM) collaboration model by involving different private practitioners working in the field of tuberculosis diagnosis and treatment in Sunsari, Morang & Jhapa districts of Eastern Nepal.

Methodology: All stakeholders including private medical colleges, private practitioners who were involved in treatment of TB cases were requested to participate in the study at different venue/place of Sunsari, Morang & Jhapa, during last few years (2010—013). They were provided training on Directly Observed Treatment Short course (DOTS) module as well as International Standard of Treatment care (ISTC) in phase wise multistage. Initially medical doctors were trained followed by laboratory personnel’s and all paramedics. All health care workers including Private practitioners were provided regular training, orientation and workshops for searing necessary information related to recent changes adopted by NTP regarding Treatment of TB, DR TB & TB-HIV co-infection and the referral system, follow-up of cases. In addition to routine cases, TB cases diagnosed by private practitioners through sputum microscopy, EP cases were also advised to register with the district TB control program and medicines were provided by NTP. After intervention of PPM- DOTS change in Case Detection Rate were estimated.

Results: An increased number of sputum smear positive cases were found in Jhapa district in the intervention period, it was found that new smear positive case were 85%, in 2066/67,

59


76% in 2067/68 and 72% in 2068/69 respectively. Similarly new case detection rate was high in Morang district in initial period of intervention that is 60% in 2066/67, whereas slightly decrease in 2067/68 (59%) & 2068/69 (53%). In Sunsari it was found that new positive case detection rate 65% in 2066/67, whereas 2067/68 - 60% and 65% in 2068/69% respectively.

Conclusion: The improvement in case detection rate was significant as this moderately added to the total number of cases detected during the study period. As estimated new case finding rate was not meet in Sunsari & Morang may be due to our constant and limitation of budgeting system as well as political instability in this duration.

Perception of Government Knowledge and Control over Contributions of Aid Organizations and INGOs to Health in Nepal: A Qualitative Study

Radheshyam Krishna KC2, Aditi Giri1, Prashant Khatiwada1, Bikram Shrestha1,

1 Kathmandu University School of Medicine, Dhulikhel

2 Patan Academy of Health Sciences, Patan Hospital

Correspondence: Radheshyam Krishna KC, [email protected]

Background: Almost 50% of the Nepali health budget is made up of international aid. International Non-Governmental Organizations working in the field of health are able to channel their funds directly to grass root level. During a 2010 conference, the Secretary of Population stated that the government has full knowledge and control over all funds and projects coming to Nepal. However, there are no documents to support this.

Objectives: The main aim of this study is to assess government and partner perceptions on whether Government of Nepal currently has full knowledge of contributions of international aid organizations and International Non-Governmental Organizations to health in Nepal and to assess if the government is able to control all foreign contributions to fit the objectives of Second Long Term Health Plan (1997–2017).

Methods: A qualitative study was performed along with available literature review. Judgmental and snowball sampling led to 26 in depth interviews with key informants from the government, External Development Partners and International Non-Governmental Organizations. Results were triangulated based on source of data. Representatives of the Department of Health Services declined to be interviewed. Data collection was done until researchers felt data saturation had been reached with each group of key informants.

Results: While Ministry of Health and Population leads the sector wide approach that aims to integrate all donor and International Non-Governmental Organization contributions to health and direct them to the government’s priority areas, questions were raised around its capacity to do so. Similarly, informants questioned the extent to which Social Welfare Council was able to control all International Non-Governmental Organizations contributions. Political tumult, corruption in the government, lack of human resources in the government, lack of coordination between government bodies, convoluted bureaucracy, and unreliability of donor and International Non- Governmental Organization contributions were identified as the main reasons for difficulties in aid integration.

Conclusions: Despite its commitment to coordinate and control development assistance

60


to the health sector, and its leadership position of the Sector Wide Approach, complete knowledge and effective coordination of all international contributions remains a challenge and is hampered by issues within the government as well as among External Development Partners and International Non-Governmental Organizations.

Activation of HFOMC for HRH Management: Impact of HRH Pilot Project

Kopila Shrestha1, Badri Subedi1 and Chandra Kumar Tiwari1

1 Indreni Social Development Forum Correspondence: Kopila Shrestha, [email protected]

Case One:

Harnampur Primary Healthcare Centre (PHC), located in Harnampur VDC of Kapilvastu district covers eight VDCs through its service. Though the PHC is well equipped with sufficient infrastructure, the dispute among health facility operation and management committee (HFOMC) has been hampering the smooth delivery of health services. In the last 7 months, the HFOMC could not hold any meetings to discuss issues of the health facility. In addition to that, one ambulance driver and security guard recruited under internal resource of PHC were not getting their salaries for the last 3 months. Similarly, the centre was not able to provide 24-hour delivery service though there was a birthing unit. Out of total 13 sanctioned staff, only 10 were fulfilled. The reasons behind the ineffectiveness of service delivery of the centre are lack of staff as sanctioned, irregularity of available staff and disputes among HFOMC members.

Case Two:

Another piloted VDC, Mahendrakot Sub Health Post (SHP), has a different experience. This sub-health post was demoted from the Health post in contrary to the upgrading system of health institution from the lower level to the higher. Despite its demotion to SHP, it has been running a birthing center with the help of only one ANM recruited temporarily by the DHO. This was made possible only through the high commitment of HFOMC to support the sub health post. But, the condition for providing services is reeling under the shortage of attached toilet and placenta disposal pit. Despite regular sitting of management committee meetings, no move was made at the local level to improve health services.

The Changes: After the implementation of pilot project entitled ‘Support to the Health Workforce through Civil Society Engagement’, there have been remarkable changes.

In Harnampur PHC, the orientation/s programme sorted out the disputes among management committee and created an amiable environment for reconciliation. This facilitated the drafting of plan of action of the HFOMC with active involvement of the members. According to the action plan, a public hearing was held on the month of Jestha, 2070 to collect the views of local people in improving the health service.

Now, an ANM has been recruited temporarily from local resources to start the birthing center from Ashad, 2070 BS. An interaction programme was also organised to explore the resource from local authorities within the VDC and to make the civil society more

61


responsible and accountable. Now, the HFOMC is working to operate 24 hrs delivery service. As a result Coordinator of Ambulance Management Committee, Bali Mohammad has committed to transform the Primary Health Care Centre into 15-bed hospital.

Similarly, community stakeholders of Mahendrakot VDC were committed to contributing out of their pocket 50% of the total financial support needed to improve services at the PHC. The other half was borne by the VDC under the heading for of Empowerment of Women and Children. They had also developed an action plan related to HRH where the roles of local stakeholders have been clearly defined. To implement the plan VDC allocated more than 100,000 NRs to HFOMC for recruitment and toilet construction. Now, one ANM and a helper have been recruited and are working since the last one month. And in coordination with District Health Office, the construction of placenta disposal pit has also been started. At the same time, they are seeking help from community forest users group . In this way, Mahendrakot SHP is working under the support of local authorities and civil society and is heading towards success.

62


THEME: GLOBALIZATION AND MIGRATION OF HEALTH WORKERS

Brain Drain of the Health Work Force: A Global Problem

Sujan Babu Marahatta1

1 PhD (Tropical Medicine), MACE, Associate Professor Manmohan Memorial Medical College/MMIHS

Issues: Trained health professionals are needed in every part of the world. Brain drain is the large-scale emigration of a large group of individuals with technical skills or knowledge. The brain drain of health workers occurs mostly from low- and low/middle-income countries to resource-rich countries and from rural to urban areas. Various factors are contributing to brain drain eg. poor standards of living and quality of life, low salaries, lack of advanced technology, unstable political conditions etc.

Descriptions: The international migration of skilled workers, the “brain drain,” is not a new phenomenon or limited to the health sector. Migration of health workers has contributed to the current disparity in the health workforce between high- and low/middle-income nations. While high-income countries have only one-third of the world's population, they contain three-fourths of the world's physicians and 89% of the world's migrating physicians. Some 180 000 (25%) of the USA's physicians are trained abroad, with 64.4% of them from low- and lower/middle-income nations. Some 90 000 nurses (40% of the overall US nurse workforce and 14% of recently licensed nurses) are trained abroad, and the number is increasing at a rate faster than for new US-educated nurses. In Nepal, brain drain has been outlined as one of the Human Resource for Health (HRH) challenges. Beyond this other HRH challenges constitute: poor staff performance in terms of productivity, quality, availability, and competency; fragmented approach to HRH planning, management, and development; imbalance between supply and demand, and narrow skill mix; limited HRH financing; low attraction / retention in public service.

Strategies: Brain drain is likely to continue in the coming decades as part of globalization. The magnitude of the brain drain problem and its alarming increase presents a growing urgency for action. There is a clear need to urgently develop and implement strategies for addressing this issue. The pressures of migration are fueled by the growing demand from national health systems in wealthy countries, as well as by the growing trade and private commercial investment in health services. In these circumstances, there is a need to find ways to stabilize the health workforce market and reduce the negative impacts of the high mobility of health professionals, thereby improving retention. The following measures need to be applied to combat migration of health workers: improving the health workforce database, improving wages/ working conditions, payback from recipient countries and migrant health professionals, facilitating conditions for returnees, strengthening temporary engagement, task shifting, securing additional investment in the health workforce, locally relevant medical training and research etc.

Recommendations: The brain drain further weakens already fragile health services in low-income countries.There is urgent need of international consensus to address the issue of brain drain. These included building coherent national and global leadership for health workforce solutions; ensuring capacity for an informed response based on evidence and joint learning; scaling up health workers' education and training; retaining an effective, responsive, and equitably distributed health workforce; managing the pressures of the

63


international health workforce market and its impact on migration; and securing additional and more productive investment in the health workforce.

Involving Diaspora as Human Resources in the Health Sector in Nepal

Anju Devkota1, Bhimsen Devkota1, Jagadishwor Ghimire2 Rajendra Gupta2, Raj Kumar Mahato2

1 Development Resource Centre, Kathmandu, Nepal

2 Save the Children, Sinamangal, Kathmandu, Nepal

Correspondence: Anju Devkota, [email protected]

Background: Globally, health professional mobility has increased in the recent years. This continues to be one of the growing public health concerns in the developing countries, including Nepal. It is feared that, in the long term, Nepal might not be able to achieve the health related Millennium Development Goals. However, there have been some efforts going on from the part of Diaspora communities to counter the effects of brain drain through their positive engagement in the national development, though the concept is very new to Nepal. Objectives: To estimate the number of foreign nationals and Nepalese Diaspora coming to Nepal and explore the ways and process of their engagement in the health sector of Nepal. Methods: A descriptive cross-sectional study was carried out using qualitative research method with special focus on Siraha, Bardia and Doti districts. In total, 13 Key Informant Interviews were conducted at the central level in Kathmandu along with record reviews. Results: Overall, 5,120 foreign medical professionals have served to Nepal through NMC followed by 739 nursing professionals through NNC and 189 paramedical staff through NHPC as of 4th November 2012. Regarding outflow of Nepali health professional, a total of 2,735 students have taken eligibility certificate for MBBS and 773 students for MDs abroad. Five organizations: Nepal Medical Council (NMC), Nepal Nursing Council (NNC), National Health Professional Council (NHPC), Social Welfare Council (SWC) including Ministry of Health and Population (MOHP) were identified as they had few records of Nepali medical and health Diaspora. Nepalese Diasporas mainly come through Diaspora Volunteering Organizations, Non Resident Nepali Association and personal connections to the place of their origin and/or their family and community relationships. Nepalese Diasporas have supported as health specialists, health camps organizers, hospital promoters, trainer for short and long term, organizer of health projects and rehabilitation centers for disabled children, supplier of materials and equipments including ambulances etc. The Nepalese Diasporas are unrecorded with professional organizations such as NMC and NHPC. As such the real status and results of support from Nepalese Diaspora are not known.

64


Conclusions: Systematic information on number and characteristics of the Nepalese Diaspora and their role in the health sector of Nepal is scant. A proper mapping and a clear process of their involvement in Nepal's health sector is not in place. The health professional bodies have some record systems but they lack uniformity and systematic process. There is no serious concern on the part of the government to neither systematize the Diaspora involvement nor appointment of a focal point/appropriate desk to coordinate the Nepali health Diaspora. It is high time that MOHP take a lead to ensure systematic involvement of the Nepali Diaspora in Nepal.

Causes, Consequences and Remedies of Migration of Human Resources for Health (HRH) from Developing Nations in the Globalized World

Hom Raj Dahal1

1 Ph D Scholar, Faculty of Humanities and Social Sciences, Trichandra Campus, TU, Vice President, Former MPS Forum

Correspondence: HomRaj Dahal, [email protected]

Background: Globalization has spread its tentacles in most part of developing countries like Nepal. Globalization is defined as the “intensification of worldwide social relations” or “the compression of the world and the intensification of consciousness of the world as a whole”. This intensification of global relationship via virtual culture has accelerated migration of Human Resources for Health (HRH). The migration of HRH via globalization results in:

Poorer countries suffering disadvantages The shift to outsourcing Weak labor unions Increase in exploitation of child labor.

Migration has two faces: emigration and immigration. According to the latest census of Nepal, about 2 million youth population immigrated to the foreign countries for studies, jobs and for permanent residence. Some section of the immigrants is of human resources for health. They are specially doctors, nurses, community health workers. But some portion of HRH entered Nepal after the democratic revolution of 2007 BS. Brain drain has adverse effect on HRH to immigrate. This situation has prompted to study HRH migration in the globalized world. Objectives: The major objectives of the study were to describe effects of globalization on migration of Human Resources of Health (HRH), to study the experiences of HRH in immigrated location and to recommend to solve immigration of Human Resources of Health (HRH) for benefit of the developing nations. Methods: Quantitative and qualitative data were collected for the analysis. Primary Data were generated from direct contact with the health workers. Secondary data were collected from books, internet, newspapers etc. After careful analysis, conclusions were drawn. Results: Globalization has become a major discourse in the 21st century. Health sector is globalised. There are many challenges to solve for Nepal government to stop migration

65


.Some of the health workers are in good condition after migration. Many have abandoned health sector jobs and opted for unskilled or semi skilled jobs. They are in unnoticed condition there. A small amount of remittance returns from these persons to Nepal. Conclusion: Of the about 2 million youth that migrated from Nepal to the other countries, a large number of health professionals have been staying in these countries permanently. Some are in good condition doing respectable medical practices. A arge number is in other sectors. They are in stressful situation. From national perspectives, brain draining of cream human resources is an alarming situation. Love for motherland and feeling for fellow citizens should be immersed in the socializing process for the youth. Providing respectable jobs, assuring bright future and healthy atmosphere to work in health institutions is necessary to check migration. Salary and facilities, scope for further studies, education and other facilities for children are the things the state has to manage for the HRH in Nepal.

____________________________________________________________________

Effectiveness of Human Resources for Health Pilot Project in Kharkada Sub-Health Post

Hari Awasthi1, Ashok Ojha1, and Prakash Chandra Mishra1

1Community Rural Development Society, Darchula

Correspondence: Hari Prasad Awasthi, 9841251029

Situation: Kharkada sub health post (SHP) is located in Darchula district of Lekam area. There are 575 households with a total population of 2, 977 (1367 males and 1610 females). In Kharkada SHP, there are one AHW, one MCHW, and one VHW in sanctioned posts whereas two ANMs are appointed by VDC. Even though, many people are getting services from the SHP, the services are not running effectively due to the lack of infrastructure and human resources services. The health workers of the SHP claimed that improper and ineffective healthcare services are due to lack of delivery equipments and skilled birth attendants.

The president of health facility operation and management committee (HFOMC) said that health services are being effective after the launch of HRH pilot project. Even though, it has its own building of 3 rooms, delivery service was providing through community building of VDC.

The Changes: After implementing HRH project, the VDC handed over the community building to SHP to fulfil the demand of community stakeholders. This was one of the important achievements of the programme. Before this programme, there was only a wooden bed in the birthing centre, which was in poor condition. The DHO had provided a modern delivery bed after the approach by HFOMC through this project. This project reactivated the HFOMC to discuss the issues of health facility for regular health services and to organise regular HFOMC meeting as per its guideline.

The Kharkada VDC had supported salary of two ANMs on contract basis. Among them one ANM was already trained as an SBA. The HFOMC also lobbied for SBA training to another ANM. The DHO further made commitment to provide one additional ANM for operating 24 hours safe delivery service. In addition to the HRH component, this project agreed to provide delivery equipments within Asad, 2070 BS. The pilot project organised stakeholders

66


meeting, public hearing and developed an action plan to improve the situation of health service delivery. During the public hearing, the stakeholders made commitment to reduce home delivery in this VDC by making aware about birthing centers to the community people. In the past, home delivery and institutional delivery were almost in equal proportion, but now, home delivery is in a decreasing trend. This is a good example of HRH pilot project bridging in the gap between the community people and the service providers to provide quality health service.

67


THEME: MEDIA COVERAGE FOR HUMAN RESOURCES FOR HEALTH ISSUES

Human Resource for Health in Nepali Print Media

Atul Mishra1, Padamraj Joshi2 and Arjun B. Kumal3

1Chief Sub-editor, Kantipur Daily 2Senior Reporter, Annapurna Post 3 Save the Children Country office Nepal Correspondence: [email protected] and [email protected] Background: Coverage of health in Nepali print media is quite a recent phenomenon despite readers’ ample appetite for it. Dominated by politics, Nepal's print media hardly saw any coverage of health before the health beats were established 15 years ago. Since then, gradually, Nepali print medium has seen publishing news pieces, features, editorials and op-ed articles or even photographs and cartoons on health. But the media did not wake up to human resources for health issues in a systematic way until very recently. Methods: We used mixed methodologies – quantitative and qualitative - in analyzing the media content in select Nepali print media – Kantipur, Nagarik and Annapurna Post for a comparative study. We did not only analyse the content of these three papers over three months in 2012 selected at the interval of three months but also interviewed government officials and journalists to make a comparative study of the coverage of human resources for health issue in the Nepali print media against overall health issues and political issues. Results: In three months, Nepal's three major dailies published in Kathmandu - Kantipur, Nagarik and Annapurna Post – published 544 health news pieces which is 44% against the political news pieces of 1, 235. Zeroing down on human resources for health, these papers published 131 news pieces - 24% of health news and just 11% of political news. However, 10% of the health news makes to the front pages and only 3% of the HRH news makes to the front pages. In comparison to news pieces, editorials, features, op-eds, photographs, cartoons and letters to the editor on health fare less well against political issues. For example, only 7% of the editorials are relating to health and only 2% of editorials were related to HRH. Conclusion: Health is prioritized far less by the print media than politics despite the reader's appetite for it. Print media should give health a top priority, particularly in those areas that relate to health systems like human resources for health, for the change in the system will have massive impact on the lives of the people.

68


HRH Coverage in Broadsheet National Dailies: A Content Analysis

Raju Prajapati1, Bhuwan Baral1, Chetnath Acharya2 and Latshering Glan Tamang1

1 Society for Local Integrated Development Nepal (SOLID Nepal) 2 China Radio International

Correspondence: Raju Prajapati, [email protected]

Introduction: It is well known that the mass media is an important social institution in any modern society. Mass media displays information about health and health related issues and make people aware. It has the power to direct people's attention towards certain issues. Print media is one of those that could impose greater impact on health related information and health seeking behaviour. The print media provides considerable amount of information and has power to sensitise the policy makers in health and HRH issues.

Objective: The purpose of the content analysis is to study systematically on human resources for health (HRH) related publications in different print media (broadsheet dailies).

Methods: Media content analysis was conducted on the HRH related messages that appear in the broadsheet national dailies. A total of 10 national dailies subscribed by Society for Local Integrated Development Nepal were used for the study which included 3 English and 7 Nepali daily newspapers. The descriptive, cross-sectional study covered HRH related news, views, editorials and investigative reports published in between April 2011 to March 2012. From a total of 1074 reportings all across the nation, sample size (89) was determined using standard formula n=[DEFF*Np(1-p)]/[(d2/Z2

1-α/2*(N-1)+p*(1-p)] at 95% confidence level and 10% confidence limit with design effect 1.0 using systematic random sampling technique.

Results: Among the 10 broadsheet national dailies, Nagarik daily had the highest coverage (18%) on HRH issues whereas The Himalayan Times and Republica had lowest coverage (both covered 4%). 86% the coverage was news stories followed by 6% editorials, 5% features and 3% opinions. Analysis of news placement showed that only 10% media coverage on HRH was published with high priority either on first page or as editorial. Nearly half (45%) of the media coverage were published with priority and 34% as common news. The HRH news covered only half geographical territory of the nation. There was not any HRH news from 37 districts. Out of 75 districts, only 7 districts had coverage of 3 or more HRH related issues. Kathmandu district alone had 37% news coverage on HRH issues. Content analysis revealed that most of the media coverage covered more than one aspect. 95%of coverage highlighted some issues of scholarship and recruitment which was followed by physical disturbance (86%), treatment errors (82%), migration of HRH (80%) and retention of HRH (73%) respectively. Likewise, 72% news coverage focused on some issues of trainings whereas only 59% highlighted issues of distribution and only 26% gave emphasis on competencies of HRH. Conclusion: The print media analysis on HRH issues were mostly covered from city areas and mostly focused on events reporting rather than investigative reports. The city centered coverage put back the rural HRH issues where availability of health workers has greater value as compared to urban ones. The study concluded that investigative reports from rural and remote places could have greater policy impact in providing quality healthcare services.

69


Mass Media's Role in Ensuring Human Resources for Health

Laxman Datt Pant1

1Communications Expert, UNESCO

Correspondence: Laxman Datt Pant, [email protected]

The importance of communication in health related issues is high because people need information not only to understand the depth of their problems but also to interact with each other and to find solutions. Human Resource for Health (HRH) is seen as human’s common need and a means to eradicate poverty and protect life. The use of the mass media can be beneficial in addressing the challenges of HRH and it could provide “cues to action” helping to improve the availability of adequate human resources for health.

The role of Mass Media in ensuring adequate human resources for health could be safely framed through a fine mixture of three inter-dependent components: free press, democracy, and health development dynamics. The first emphasizes information as the key to make people conscious of their health rights while the second stresses grass-root people's participation in health activities. The third talks of various realities – political, economic, technical, social, and financial – that people face in accessing health resources.

There is a clear role for the media to contribute to the cause of HRH in the country. Media persons could engage in the process in following ways: -

a) just disseminating information about challenges associated with HRH: events and issues related to it

b) adopting HRH as an agenda for initiating public discussion c) championing the cause of HRH as its mission

The editorial policy of media houses itself appears unclear on coverage of HRH issues. Media owners also seem to be not interested in inserting HRH issues in their media - portfolio. This reflects in media products and journalistic capacity of media-person-power.

Nepali media newsrooms could work out a comprehensive plan for covering HRH in full dimension and perspective. Their stories could concentrate on information dissemination and education, behavior change, social mobilization, policy analysis, best practices, lessons from failures, communication for social change, and people’s participation.

The mass media can have a particular impact where people are already motivated to change. Preparing newsroom for development communication with emphasis on local development:

Clarifying editorial policy Mobilizing reporters, editors: making them skilled, equipped and motivated for

covering HRH issues and events Recognizing journalistic works: honouring them from time to time Developing journalists' network for intensifying Health Communication dialogue Sensitizing decision makers on the importance of responding to issues raised by

press in HRH

70


State should engage in enabling media to cover health particularly HRH, and activities related to Millennium Development Goals such as child health, maternal health and combating HIV /AIDS

Challenges

Newsrooms face a number of non-press challenges in covering HRH issues. Some of the pressing ones are mentioned below:

Conflict-situation hinders media dissemination Non-state actors seek to control press, press safety in question Partisan approach hinders presentation Confusion about Interim Plan Absence of elected bodies at local level Media product marketing strategy not interested in development press matters

Way Out

The media have the responsibility to ensure that stories they disseminate is accurate and adequate. Editors, publishers and producers should consult with representatives or members from one of the range of appropriate professional bodies with an interest in Human Resources for Health. On the other hand, encouraging owners to tolerate health communication in editorial policy would be a brilliant idea. It has to be backed up by an active package for empowering Newsroom for health communication.

71


OPEN PAPERS

Human Resources — Accounting and Auditing

Janak Raj Gautam1

1 Assistant Auditor General, Office of the Auditor General

Correspondence: Janak Raj Gautam, [email protected]

A sound human resources management can provide employees a rewarding professional environment for discharging their duties and enhancing the capabilities of them. As a result, a well-trained and professionally competent work force plays a significant role in achieving high quality outputs. For this, there are certain human resources policies. One of them is recording and accounting of human resources and evaluation of the same. The major aim is to support management for applying principles, policies, procedures, practices, processes and precedents on human resources in future with financial implications of various practices. The quantification and measurement of the value of human resources helps the management to cope with the changes in its quantity and quality. It also helps the employees to understand their contributions towards the betterment of the entity and improving their performance. At present, human resources accounting of an organisation that are not separately accounted but they are recorded only according to the conventional accounting practices of our government system.

Human resource accounting provides useful information to the management, employees, researchers and other practitioners for decision making, suggesting, implementing and utilizing the same. In order to achieve the cost effectiveness of organizational objectives, it is essential to furnish cost value information for making proper and effective management decisions about acquiring, allocating, developing and maintaining human resources. There are certain cost models for acquisition, replacement, training costs and investment for capacity building. Among them, we may implement any few to find out the actual scenario of expenses for human resources and their contributions. We use suitable, understandable, comfortable and useful models to match to our context.

A human resources accounting is a comprehensive method to analyse human resources policies, procedures, documentation and systems through verification of records and accounting information for identifying requirements to make better use of the same. It is the process of identifying and reporting the expenditures made in the human resources organizing and recording the data and information of expenditures for translating them in accounting language. The term used to describe the accounting methods, systems and techniques, which coupled with specific knowledge and ability to assist personnel management in the valuation of trained manpower and motivation to be in the same profession. Management is hesitant to introduce with proper clear cut and specific procedures and guidelines for finding costs and value of human resources accounting because of uncertainty in valuing them.

To monitor effectively the audit goes beyond more than just looking at personnel files to make sure they're complete and consistent with laws pertaining to employment practices. In this paper the need, objectives, approaches to record the HR expenditure and accounting

72


of HR records will be elaboraed particularly in the health sector. Eventually, the significant and process of audit of the same will also be elucidated with a reference of various reports.

Users Perspectives on Barriers to Receive Reproductive Health Services in Selected Public Hospitals of Nepal

Binjwala Shrestha1

1Assistant Professor, Institute of Medicine Correspondence: Binjwala Shrestha, [email protected] Introduction: “Quality reproductive health care” goes beyond the narrow family planning concept to encompass the overarching issues about women's general health. It aims at promoting healthy pregnancy, reducing infant and maternal morbidity and mortality and alleviating suffering and disease. To provide high-quality reproductive care, providers must understand and respect their clients' needs, attitudes, and concerns. Improving quality of care requires objective analysis of the services to be able to have full understanding of patients’ perspectives and the level of satisfaction. Objective: to describe women service users’ level of satisfaction towards RH services in selected hospitals of Nepal. Methods: Semi-structured interviews conducted with 217 women (who visited hospitals to use RH services) in six public hospitals of Nepal. Among the total study participants, 41.47% were from Kathmandu – based TUTH and 20.28% from Maternity Women’s Hospitals, 19.35 from Dang District Hospital, and 18.89% from the Western Regional Hospital, Pokhara. Results: Type of RH services used: Family Planning (FP) and Antenatal Care (ANC) service (38%), delivery services (25%) and Gynaecology OPD (23%). Among them, 68% service users visited hospitals more than one time. Profile of study participants: The age group of the women ranged from 12-62 years. Among them29% had education up to secondary level and 14% women were literate. 50%, of them were Bramins/Chhetris, 40% Janajatis and 10% Dalit. 86% of households were headed by men members and 91% of the decision makers were men. Perception of quality of care of received RH services: The waiting time to get services at the hospitals is found to be somewhere between one to more than 2 hours. Perception on communicating with service providers: 86% expressed satisfaction because they could express their problems with service providers. However, 14% said they could not express their health problem properly due to shyness (N-11), language barrier (N -27) and some kind of unknown fear (N-2). 80% women were satisfied with service providers’ behavior. However, 20% were not satisfied due to lack of privacy, not responsive to questions. About 19% (N-43) informant experienced impolite behavior and even harassments from the service providers. 61% preferred women service providers preferred female service providers. Their main concerns were the sensitivity and skill of the service providers in understanding and managing their problems properly.

73


Conclusions: It was clear that some of the women service users were not satisfied with RH services, privacy, long waiting time, unfriendly behavior of service providers due to lack of communicative skills, sensitivity and lack of female service providers were the main issues related to dissatisfaction. Therefore, HRH policy should consider to prepare sensitive and receptive women health service providers with adequate communication skill for RH service delivery.

Reactivation of HFOMC for HRH Management at Baneshwor HP: A Success

Amrit Dangi1, Dipan Kumar Shrestha1 and Rudra Dahal1

1Astha Forum for Infrastructure Development, Sankhuwasabha

Correspondence: Amrit Dangi, [email protected]

The Situation: The Baneshwor Health Post (HP) is in Sankhuwasabha District. The health facility operation and management committee (HFOMC) of Baneshwor HP was formed in 2056 but remains inactive since there was no co–ordination and communication between HFOMC and the HP in–charge or staff. HFOMC even doesn’t know whether the in–charge or staffs have gone somewhere or stayed at home on leave.

Introduction of the Case under Study: Baneshwor Health Post is under shadow due to carelessness of HFOMC. Four years ago, the HP was functioning as a sub-health post with only 3 staff. During a public hearing, it was raised that it was the HP in-charge who should inform the HFOMC but on the contrary, the HP staff feared that they would face problems if HFOMC became active and alert.

Recently, AFID has launched the Pilot Project of Human Resource for Health because of which the HFOMC and local people have become enthusiastic. They opined "this project will alert the HP staffs as well as the District Health Office." They said "After the implementation of the project, the health workers are regular, and the members of HFOMC have also realized their duty, responsibility, working field and rights.

The Change or the Uniqueness: Though local people's participation for the physical and qualitative development of Local Health Post and to receive health services are the fundamental rights, Baneshwor Health Post is unable to provide quality services in the lack of awareness and vigilance. Before the project's intervention, the HP was not receiving people's acceptance, assistance and cooperation but now the situation has improved a lot.

The following changes have been observed after the implementation of the project activities:

Reformation of HFOMC,

Decision to regularize HFOMC monthly meeting which is held on the 4th of every month,

It was decided that the audit of the last 4 years' financial transactions to be done by 14 Asad 2070,

The HP In-Charge has to call the HFOMC meeting,

74


VDC and HFOMC have corresponded with the agencies concerned to initiate the birthing center, VDC committed to support even after the project's exit, and the meeting of DHO and AFID decided to proceed for the appointment of an SBA,

Income and expenditure of the Health Post has been publicized and

It was decided to manage the problem of drinking water within a month.

Conclusions: Vigilance and zeal have been created among the people of Baneshwor VDC as a result of advocacy and different project activities conducted for pilot projects of Human Resource for Health.

Tangible progress was achieved within the short period of project implementation. This reflects the rationale and inevitability of the project.

Regularizing the services from heath workers and maintaining transparency in financial transactions of the health posts are the major achievements of the project.

i


ANNEXE

ANNEXE 1: COMMITTEES FOR CONFERENCE A. Advisory Board Secretary – MoHP, Chairperson Joint Secretary HR and Financial

Management Division - MoHP, Member Director General – Department of Health

Services , Member Joint Secretary – Social Development

Division, NPC, Member Joint Secretary – Public Service

Commission, Member Joint Secretary – Ministry of Finance,

Member Joint Secretary – Ministry of Education,

Member Joint Secretary – Ministry of Local

Development , Member Mr. Raj Kumar Mahato, Program Manager,

Health and Nutrition, Save the Children – Member

Mr. Mukunda Adhikari, MoHP, Member Secretary

B. Technical Committee Dr. Dipendra Raman Singh – Chair Prof. Dr. Chop Lal Bhusal – Member Prof. Dr. Arjun Karki –Member Prof. Dr. Jeevan Sherchan - Member Associate Prof. Dr. Bhimsen Devkota -

Member Asso. Prof. Dr. Sujan Marahatta –Member Dr. Poonam Rishal - Member Mr. Anant Nepal - Member Dr. Tirtha Rana –Member Dr. Khem Karki –Member Mr. Jagadishwor Ghimire – Member

Secretary C. Organizing Committee Joint Secretary HR &FMD – MoHP, Chair Mr. Mukunda Adhikari- MoHP, Member Mr. Shanta Lal Mulmi - CSO/NSA Alliance,

Member

Dr. Rameshwor Pokhrel - CSO/NSA Alliance, Member

Dr. Poonam Risal – BNMT , Member Dr. Khakindra Bhandari – MERLIN,

Member Mr. Bhuwan Baral – SOLID, Member Mr. Rajendra Gupta – SC, , Member

Secretary Under the Organizing Committee, there were five sub-committees:

1. Finance Sub-Committee Mr. Yam Narayan Sharma, MoHP Mr. Deepak Kumar Bishwakarma, SC Ms. Sajana Amatya, MERLIN Mr. Binod Maharjan, SOLID, Nepal Mr. Laxmi Dahal, BNMT

2. Event Management Sub-Committee Ms. Ashmita Hada– SC, Coordinator Mr. Ananta Nepal, MERLIN Ms. Rinju KC, BNMT Mr. Januka Sunedi, MoHP Ms. Chandika Shrestha, MERLIN Mr. Raju Prajapati, SOLID Nepal Ms. Sambida Regmi, WHR

3. Logistics Sub-Committee Mr. Deepak Kumar Bishwakarma, SC Ms. Soma Rai, BNMT Mr. Daman Baij, MERLIN Ms. Manju Neupane, SOLID

4. Publication Sub-Committee Mr. Niranjan Thapa - SC Mr. Narayan Sharma – BPMHF Ms. Sumnima Shrestha - BNMT Ms. Januka Subedi, MoHP

5. Media Relations sub-Committee Mr. Mukunda Adhikari, MoHP Mr. Arjun B. Kumal, SC Dr. K. Bhandari, MERLIN Mr. Keshab Gyawali, MoHP

Conference Coordinator: Jagadishwor Ghimire, Save the Children

Editor: Arjun Bahadur Kumal, Save the Children

ii


ANNEX 2: PROGRAM SCHEDULE National Conference on Human Resources for Health

June 14-15, 2013 Hotel Yak & Yeti, Kathmandu, Nepal

Day 1- Friday, June 14, 2013

Time Programme Responsibility Remarks Inauguration Session

8:30 - 9:15 Registration of Participants and Tea Coffee Event Management Committee

9:15 - 9:25 Sitting on the Dias/Chair Chair and Delegates

9:25 - 9:40 Documentary show Arjun Kumal

9:40 - 9:45 Opening Ceremony Chief Guest Bidhya Dhar Malik, Hon. Minister, MoHP

9:45 - 9:55 Welcome Address Kedar Bahadur Adhikari, Joint Secretary, MoHP

9.55-10:05 Remarks from EU Dr. Alexander Spachis, EU Ambassador to Nepal

10:05 – 10:00 Remarks from WHO EDP Representative, WHO

10:10-10:20 Remarks from Chief Guest Chief Guest Bidhya Dhar Mallik, Hon. Minister, MoHP

10:20 - 10:30 Closing of the Opening session Dr. Praveen Mishra, Secretary, MoHP

10:30-10:45 Tea Break

Scientific Sessions Plenary Session (10:45 - 1:00)

Time Topic Presenter Chair Co-chair

10:45-11:05 Community Based Health Workers: Policy Perspectives in Nepal

Dr Rita Thapa Prof. Dr. Jagadish Agrawal

Dr. Sushil Baral

11:05-11.25 HRH Planning and HRH Management Approaches with a Global and National Outlook

Dr. Wilma Meeus, International HRH Expert

11.25-11.45 HRH Strategy and Workforce Planning in Nepal

Kedhar Bahadur Adhikari, MoHP

11:45-12:00 Health Sector Reform in Nepal Dr Baburam Marasini

12:00-12:25 Sharing of Findings of Regional Workshop of HRH

Dr. Aruna Uprety

12:25-12.45 So Much Depends on the Healthcare Worker

Dr. Mark Zimerman

12:45-1:00 Discussions and Closing of Sessions Chair/Co-chair

1:00 -1:45 Lunch Break

Parallel Session I Hall A: HRH Status in Nepal (1:45 - 2:55)

Time Topic Presenter Chair Co-chair 10 min Production of Human Resources for

Health in Nepal Rajendra P. Gupta

Dr. Chet Raj Pant

Dr. Buland Thapa

iii


10 min Human Resources for Health in Nepal: A Situational Analysis

Anant K. Nepal

10 min Situational Analysis of Human Resource for Health in Public and Private Sectors in Nepal

Ms. Rinju KC

10 min National Status of Health workforce in Nepal

Dr. Khem Karki

10 min Human Resources for Health in Ayurved Sector of Nepal

Dr. Madhab Prasad Lamsal

20 min Discussion and Closing of Session Chair/Co-chair

2:55-3:05 Tea Break

Hall B: HRH Distribution and Skillmix in Nepal (1:45 - 2:55)

10 min The Distribution and Skill mix of Human Resources for Health in Nepal

Dr. Khakindra Bhandari

Dr. BD Chataut

Dr. Aruna Uprety

10 min Optometrists as Human Resource for Health in Nepal

Subodh Gyawali

10 min Integration of Pharmaceutical Care in Health Services: Policy Review

Bhupendra Thapa

10 min Access to DR TB Services in Far Western Development in Nepal

Dr. Suhubhesh Raj Kayastha

10 min Role of HFOMC in Lele PHCC for HRH management: An Example

Achut B. Ojha

20 min Discussion and Closing of Session

2:55-3:05 Tea Break

Parallel Session II Hall A: Deployment, Placement and Retention of HRH (3:05- 4:00)


10 min Responding to Increased Demand for Institutional Childbirths at Referral Hospitals in Nepal: Implications for Human Resources

Prof. Dr. Madhu Dixit Devekota

Prof. Dr. Chop Lal Bhusal

Dr. Sujan Marahatta

10 min Predictors for the Choice of Future Practice Location among Graduating Medical Students: Perspective from Social Cognitive Career Theory in Nepal

Bhim Prasad Sapkota

10 min Nursing Human Resources on Present Situation and its Attraction and Operation in Relation to Standard Guideline of nursing workforce

Ishwori Shrestha

10 min Training, Recruitment, Placement and Retention of Health Workforce in Nepal

Raju Prajapati

15 min Discussions and Closing of Sessions Chair/Co-chair

4:00 - 4:10 Tea Break

Hall B: Career Development (Education/Training) for HRH (3:05 - 4.00)

10 min Career Intentions of Medical Students in Nepal

Dr. Sunil Joshi Prof. Dr. Jeevan

Bahadur Sherchand

Mrs. Kiran Bajracharya

10 min Beyond Training – The Follow-up Enhancement Program

Shovana Rai

10 min Human Resources for Health : Career Development Perspectives

Shankar Raj Lamichhane

iv


10 min Medical Students’ Characteristics as Predictors of Career Practice location: Retrospective cohort study Tracking Graduates of Nepal’s First Medical College

Rabina Shakya

15 min Discussions and Closing of Sessions Chair/Co-chair

4:00 - 4:10 Tea Break

Parallel Session III

Hall A: Motivation of Health Workers (Performance and Accountability) (4:10 - 5:30)


10 min Motivation and Retention of Health workers

Jagadishwor Ghimire

Prof. Dr. Arjun Karki

Prof. Bishnu Bhattrai

10 min Health Workforce Performance and Accountability

Chandika Shrestha

10 min Working Conditions of Health Workers in Nepal

Manju Neupane

10 min Job Satisfaction of Health Workers Working at Peripheral Health Institutions in Siraha District

Sumit Karna

10 min Patient Satisfaction with Nursing Care in Different Hospitals of Kathmandu Valley

Gita Dhakal Chalise

30 min Discussions and Closing of Sessions/Day

Hall B: HRH Policy and Management (4:10 - 5:30 )

10 min HRH Gap Analysis in Relation to National Objectives and Priorities

Raj Kumar Mahato

Prof. Dr. Rajendra Raj

Wagle

Mr. ParshuRam Shrestha 10 min Human Resources for Health (HRH)

Management from Central to District Level in Nepal

Anant Nepal

10 min Health Governance at Local Level from Human Resource for Health Perspectives: A Case of Nepal

Bhim Sen Devekota

10 min Human Resource for Health in Nepal: Analysis of Policies and Practices

Dr. Poonam Risal

10 min Human Resource for Health: Views of Public Service Commission

Khagendra P. Subedi

30 min Discussions and Closing of Sessions/Day

Day II – Saturday, June 15, 2013

Panel Discussion

Time Topic Panel Members Moderator Rapporteur

8:30-9:00 Registration/Tea Coffee

9:00 - 10:30 Investing in Human Resource for Quality Health Services in Nepal

Prof. Dr. Jagadish Agrawal, IOM Prof. Dr. Arjun Karki, PAHS Dr. Babu Ram Marasini, MoHP Dr. Damodar Gajurel, NMC Ms. Daya Laxmi Joshi, NNC Dr. Ram Hari Ghimire, CTEVT Dr. Anjani Kumar Jha, NMA Mr. Ram Bhandari, NEPHA Dr. Khem Karki, CSO/NSA

Dr. Tirtha Rana

Dr. Khakindra Bhandari

v


Plenary session


10:30-10:50 Aligning HRH and National Health system: Challenges and Opportunities

Prof. Dr. Arjun Karki

Dr. Rita Thapa

Prof. Dr. Ram Prasad

Shrestha 10:50-11:10 Role of Private Sector in HRH production Prof. Dr.

Hemang Dixit 11:10-11:30 Discussions and Closing of the Sessions Chair/Co-chair

11:30-11:45 Tea Break

Parallel Session IV

Hall A: Public Private Partnership for HRH (11:45 - 12:45)

10 min Role of Civil Society in Human Resource for Health Management in Nepal

Bhuwan Baral Dr. Janardan Lamichhane

Dr. Rajendra Kumar B.C.

10 min Public Private Mix Collaboration Model in Enhancing Tuberculosis Case Detection: An experience from Eastern Nepal

Dr. Deepak K Yadav

10 min Perception of Government Knowledge and Control Over Contributions of Aid Organizations and INGOs to Health in Nepal: a Qualitative Study

Dr. Radheshyam Krishna KC

10 min Activation of HFOMC for HRH Management: Impact of HRH Pilot Project

Kopila Shrestha


12:45-1:45 Lunch Break

Hall B: Globalization and Migration of Health workers (11:45 - 12:45)

10 min Brain Drain of the Health Workforce: A Global Problem

Dr. Sujan Babu Marahatta

Kedar Bahadur Adhikari

Dr. Rameshwor Pokharel 10 min Involving Diaspora as Human

Resources in the Health Sector of Nepal

Anju Devkota

10 min Causes, Consequences and Remedies of Migration of Human Resources for Health (HRH) from Developing Nations in the Globalized World

Hom Raj Dahal

10 min Case Study Hari Awasthi


12:45-1:45 Lunch Break

Plenary session: Media Coverage on HRH Issues (1:45-2:35)


10 min Human Resources for Health in Print Media

Atul Mishra and Padam Raj Joshi

Dr. Tirtha Rana

Rajendra Dev Acharya

10 min HRH Coverage in Broadsheet National Dailies: A Content Analysis

Latshering Glan Tamang

vi


10 min Mass Media's Role in Ensuring Human Resources for Health

Laxman Datt Pant

20 min Discussions and Closing of session

Open Papers

Time Topic Presenter Chair Co-chair 2:35-2:50 Human Resource : Accounting and

Auditing Janak Raj Gautam Dr. L. R.

Pathak Dr. Bhimsen Devekota

2.50-3.05 Users’ Perspectives on Barriers to Receive Reproductive Health Services in Select Public Hospitals of Nepal

Binjwala Shrestha

3:05-3:20 Reactivation of HFOMC for HRH Management

Amrit Dangi

3:20-3:35 Tea Break

Closing Session

Time Programme Responsibility Remarks

3:35-5.00 Sharing of the Summary, Recommendations and Closing of Two-day Conference

Technical Committee Members, CSO/NSA Member, & MoHP

vii


ANNEX 3: LIST OF PARTICIPANTS

Name Organization

Aanata Kumar Nepal MERLIN

Aarju Hamal HHESS

Achut Babu Ojha RICOD

Achyut Lamichhane DHO Bardiya

Ambar Mainali EU

Amrit Bikram Rai MRDCC, Pyuthan

Amrit Dangi AFID

Amrita Ghimire OHC,BNMT

Anil Khadka Nobel college

Anjana Shrestha KU

Anjeela Khatiwada BNMT

Anju Devkota DRC

Anju KC AMK

Anup Adhikari SOLID Nepal

Archana Gurung NTV

Arjun Adhikari Nepal 1 TV

Arjun Bahadur Kumal Save the Children

Arjun Subedi SOLID Nepal

Ashish Khadayat HRH Alliance,Doti

Ashmita Hada Save the Children

Atul Mishra Kantipur

Baburam Humagai NPA

Bal Krishna Bhusal DPHO Lalitpur

Bal Krishna Oli Bardiya Nagarik Samaga Sanjal

Banaarasi Barma District HRH Alliance, Kapilvastu

Beg Bdr. Tamang MoHP

Bhanu Dev Jaishi CICD

Bharat Bdr.Kathayat RDSC/Doti

Bhim Prasad Sapkota DPHO, Kathmandu

Bhupendra Thapa Pharmacy Consultant

Bhuwan Baral SOLID Nepal

Bichu Gaun District HRH Alliance

Bidya Mahat ADRA

Bijaya Pariyar Valley College

Bijuna Bhattarai NAMS

Bikash Thapa CWSN/ AHC

Bina Maharjahan MCUTC

Bindu Gurung Phect Nepal

Binjwala Shrestha IOM

Binod Bindu Sharma RHTC Pokhara

Binod K. Aryal Global Health Alliance Nepal

Binod k. Thapa Radio Ramaroshan

Binod Kumar Maharjan SOLID Nepal

Bipana Shrestha SOLID Nepal

Bir Bahadur Mahato BHORE,Dhanusha

Bir Bdr. Jethara HRH Alliance Kailali

Bishnu K Bhandari JWAS,Janakpur

Bishnu Nepal RSS

Bishnu Prasad Poudel LCD

Bishnu raj nepal SMNF nepal

Bishu Poudel MoHP

Brinda Bhandari ADRA

Brish Bahadur Shahi DHO Mugu

Buddhi Pd. Gautam Nepal Janauddar Assosiation

Chandeshwori tamrakar ADRA Nepal

Chandika Shrestha MERLIN

Chandra Deo Mehta DPHO, Jhapa

Chandrakala Oli MoHP

Chet Raj Joshi DHO Doti

chet raj phulara FPAN

Chetnath Acharya CRI

Chhabi Ranabhat GNI

Christian Touwaide Attache, EU

Dala Prasad Chaulagain FHI360

Dale Dawis HKI

Daman Baij MERLIN

Daman Raj Bam HRH Alliance Kalikot

Dan Bdr. Khadka BNMT

Daya Laxmi Joshi Vaidya Nepal Nursing Cousil

Deepak Adhikari CHD

Deepak Koirala Save the Children Deepak Kumar Bishwakarma Save the Children

Deependra Kafle MoHP

Dev K Yadav FNJ-Siraha

viii


Dhankala Kunwar Naradevi Ayurvedik Hospital

Dharma Bhandari BNMT

Dhruba Thapa HFL/RTI

Dila Ram Bhatta DHO, Bajura

Dinesh Adhikari BNMT

Dinesh Bhandari MSN, Rasuwa

Dinesh Pradhan FPAN

Dirgha Raj Upadhyay Radio Paschim Today

Dr Niraj Nakarmi CNCP/JSI

Dr sharada P. Wasti DRC

Dr. A.K. Chaurasiya RHD, Pokhara Dr. Anant Kumar Sharma DHO Kapilvastu

Dr. Anjana KC Thapa Save the children

Dr. B.D. Chataut CIST

Dr. Babu Ram Marasini MoHP

Dr. Badri Raj Pande Nepal Public Health Foundation

Dr. Bhabani Pd. Sharma DHO Manang

Dr. Bhagwan Koirala TUTH

Dr. Bhimsen Devkota DRC

Dr. Buland Thapa Bir Hospital

Dr. Chetraj Pant NPC

Dr. Damodar Gajurel NMC Dr. Daya Shankar Lal Karna DHO Siraha Dr. Deepak Kumar Yadav BPKIHS DR. DHANA RAJ ARYAL NEPAS Dr. Dipendra Raman Singh MOHP Dr. Janardhan Lamichhane JSI Dr. Khakindra B. Bhandari MERLIN

Dr. Khem B. Karki SOLID Nepal

Dr. Laxmi Raj Pathak NHSSP

Dr. Madhab Psd. Lamsal Kanti Children Hospital

Dr. Mingmar G. Sherpa DoHS

Dr. Nabin thapa FPAN Dr. Padam Bahadur Chand MOHP Dr. Pawan Jung Rayamajhi DHO Panchthar

Dr. Poonam Rishal BNMT

Dr. Praveen Mishra MOHP Dr. Radhashyam Krishna K.C Patan Hospital

Dr. Rajendra Bhadra HFL/Jhpiego

Dr. Rajendra Kumar BC DRC

Dr. Rajendra Pant NTC Dr. Rajendra Prasad Shah Lalitpur DPHO

Dr. Ram Bahadur K.C DHO Accham

Dr. Raman P. Singh DHO, Sindhupalchowk Dr. Ramesh Kumar Kharel DHO Rassuwa Dr. Ramesh Prashad Adhikari RHTC Surkhet Dr. Rameshowr Devkota DHO Darchula Dr. Rameshwor Pd. Pokharel IOM

Dr. Ravindra Bhupathy MERLIN

Dr. Rita Thapa PBSON

Dr. S.N Pyakurel RHD, Surkhet

Dr. Shabbir Khan Pashupati Homeo Dr. Shankhar Pratap Singh NHRC Dr. Shenedra Raj Upreti FHD Dr. Shubhesh Raj Kayastha Seti Zonal Hospital

Dr. Shyam Raj Upreti RHD

Dr. Shym Babu Yadav NARTC

Dr. Subodh Gyawali BP Foundation

Dr. Sujal Marhatta Manmohan Medical College

Dr. Sunil Kumar Joshi KMC

Dr. Suresh Mehata NHSSP

Dr. Surya Prasad Bushal DHO, Kalikot

Dr. Sushil Baral HERD

Dr. T.R. Panthi Nardevi Hospital

Dr. Thirth Raj Burlakoti MOHP

Dr. Tirtha Rana Nepal Public Health Foundation

Dr. Uma Shankar Pd. Chaudhary DHO Pyuthan

Dr. Wilma Meeus International Expert on HRH, The Netharlands

Dr.Aruna Upreti BNMT Dr.Dhiren Bdr. Pokharel BPNHF

Dr.KP Dhakal NLR

ix


Dr.Mukti Ram Shrestha NMA

Durga Prashad Bhurtel Section Officer, FWRHD

E.Ugarje V.dibility, Eu. Delication

Ek Raj Bhandari District HRH Alliance, Panchthar

Enrica Levesche MERLIN

Ful Kumari Chaudhari TWUC Bardiya

Ganesh Gyawali MoE

Ganesh Khadka WideVision Media

Ganesh kumar Pokhrel egional manager, Merie stopes nepal

Geeta Sharma UMN

Gita Dhakal Chalise NAMS

Govinda Khadka District HRH Alliance Dang

Hari Datt Bhatt RHTC DHN

Hari Krishna Bhattrai JSI R&T/CNCP

Hari Kunwar PAN Nepal

Hari Paudel BNMT, Nawalparasi

Hari Psd. Awasthi CROS Nepal

Harihar Sapkota DHO,Bardiya

Harish Chandra Shah ERHD Dhankuta Hemanta Sharma Poudel CRHTC Pathalaiya

Him Bdr. Vishwakarma District HRH Alliance, Achham

Hima Kumari Sunar FEDO,Bardiya

Homraj Dahal Tri-Chandra College

Indra Dev Yadav DDC Siraha

Indra Kanta Pant BNMT, Kailalai

Indu Tuladhar BNMT, Doti

Isha Adhikari MOHP

Ishwari Devi Shrestha MoHP

J. Morrison NSI

Jagadishwor Ghimire Save the Children

Jagat Khadka Save the Children

Janak bdr. Rokaya District HRH Alliance, Bajura

Janak Raj Gautam Office of Auditor General

Janardan Gautam DPHO Dang

Januka Subedi MoHP

Jaya Bahadur Karki DPHO Kailali

Jhalak Sharma Paudel DHO Palpa

Kalpana Acharya AV NEWS TV

Kamal Khadka NHSSP/MOPH

Kamal Prasad Tharu GERUWA,Bardiya

Kamala Adhikari TSRH, MDM france

Kedar Bahadur Adhikari MOHP

Kedar Shah Save the children

Keshab Gyawali Section Officer, MoHP

Keshab Koirala HRH Alliance Kalikot

Khagendra Psd. Subedi PSC

Khagendra Rijal MoHP

Khem Raj Upadhay RHD, Surkhet

Khob Raj Bhandari IOM,MMC

Kiran Bajracharya MIDSON

Kishor Junj Shah BNMT

Komal Raj Sarma BNMT

Kopila Kiorala RICOD

Kopila Shrestha INDRENI, Kapilbastu

Koushal Raj Vaidya T.A.Y.G pyuthan

Krishna Shrestha NSI

Kul Bahadur Kunwar MoHP

Kumar Lama MoHP

Latshiung Glon SOLID Nepal

Lawa Deva Dhunghana HRH Alliance, Panchthar

Laxman Datta Pant UNESCO

Laxman Prasad Ghimire MoHP

Laxman Regmi BPMHF

Laxmi Bista Phect Nepal

Laxmi Dahal BNMT

Laxmi Raj Joshi NHEICC

Lekha Bahadur Gurung MMIHS

Lekha Bdr Katuwal WOREC Nepal

Lok Hari Pandey PSC

Lok Raj Sanjyal NAMS

Mahendra Bikram Shah BNMT Mahendra Dhose Adhikari DHO Doti

Mahendra Shrestha NHTC

MANJU NEUPANE SOLID Nepal

Manoj Khadka USID Nepal

Maria Montero Martin Trib. Hospital

Marius Musca MDM

x


Mark Zimmerman NSI

Min Raj Panthi Action Aid, Nepal Mohan Krishnsa Shrestha TIO

Moti Kala Pangeni District HRH Alliance

Mukunda Adhikari MoHP

Mukunda Gautam DHO, Nawalparasi

Nabina Pradhananga MoHP

Nancy Gerein NHSSP

Narayan sharma BPNHF

Narendra Lama MoHP

Navamaya Limbu USAID

Nawaraj Chaulagain Tilganga Eye Center

Neena Khadka Save the Children

Netra prasad Bhatta UMN

Nimendra Shahi District HRH Alliance Bajura

Nir L. Priya Nepal Janauddar Assosiation

Niranjan Thapa Save the Children

Nisha Shrestha NAMS

Padam Raj Joshi Annapurna Post

Padma Kumari Malla HC5

Parashu Ram Shrestha FWRHD

Pariksha Rai OM

pashupati tuladhar Save the children

Poonam Joshi EPAN

Prabesh Paudel HOPE

Pragya Pokharel OM College

Prakash Adhikari SRDC,siraha

Prakash Adhikari WideVision Media

Prakash Bohara TDH

Prakash K.C MoHP

Prakash Sharma BPNHF

Pramod K Jaishwal Action Aid International Nepal

Pranaya Kumar Upadhaya DHO Shankhuwasabha

Prem K Luitel Nepal Television

Prem Poudel

DISTRICT PROJECT OFFICER, SINDUPALCHOWK

Priti Kharel University of Sheffield

Prof. Bishnu bhattarai MMIHS

Prof. Dr. Arjun Bdr. Karki PAHS, Patan Prof. Dr. Chop Lal Bhusal IOM/NHRC

Prof. Dr. J.P Agrawal IOM Prof. Dr. Jeevan Bahadur Sherchand IOM Prof. Dr. Krishna Poudel IOM Prof. Dr. Madhu Dixit Devkota IOM Prof. Dr. Rajendra Raj Wagle IOM Prof. Dr. Ram Pd. Shrestha

Manmohan Medical College

Prof. Dr.Hemang Dixit KMC Prof. Ramji Prasad Pathak IOM

Purushotam Singh Save the Children

Pushpak Newar Handicap International

Rabi Mohan Bhandari Save the Children

Rabina Shakya NSI RADHA KRISHNA ACHARYA SSPSK

Raj Kumar Mahato Save the children

Raj Nandan Mandal MI

Rajbir Yadav DHO Siraha

Rajdeo Thakur NRCS Siraha

Rajendra Dev Acharya NTV

Rajendra Dhital FNJ Bardiya

Rajendra Gupta Save the Children

Rajendra Raj Timilsina NTV

Rajesh Parajuli BNMT

Rajesh Upadhyaya Kings Project

Raju Parajapati SOLID Nepal

Ram Acharya Gangalal Hospital

Ram Bhandari NEPHA

Ram Chandra Joshi Community Development Forum

Ram chandra silwal Green Tara Nepal

Ram Sagar Chaudhary ERHTC Dhankuta Ramesh Kumar Adhikari MoLD

Ranju Sharma Medic Mobile

Rashmi Bhikshu NAMS

Rashmi K.C. NAMS

Resma Shrestha AIN

xi


Rijan Kafle HOPE College

RIKESH SINGH NEPAL 1 TV

Rinju kc BNMT Rishi Prasad Lamichhane MoHP

Rishi Ram Poudel District HRH Alliance Sindupalchowk

Rita Sharma MoHP

Rohit Acharya ACAS

Roshan Neupane Valley College

Roshan Thapa Araniko TV Rup Chandhara Maharjan Nepal PAS

Rupa Chilvers NHSSP/LATH

Sabin Kumar Sharma MoHP

Sabina Kadariya MCUTC

Sabina Rijal BNMT

Sabina Sedhai NAMS

Sadiksha Mahara MOHP

Sajan Tamang MoHP

Sajida Sidiqui HRH Alliance Dang

Sambida Regmi WHR

Sanat Kuamr Sharma DHO Bardiya

Sangita Khatrti Save the Children

Sanjaya Aireya CWSN/ AHC Sanjaya Kumar Upadhyaya

KU, Dhulikhel Medical College

Sanjita Bhattarai NAMS

Sanu Babu Maharjahan AV NEWS TV

Saraswati Adhikari NAMS

Sarita Khadka Green tara nepal

saroj dhungel Ghorkhapatra

Saroj Khadka WideVision Media

Satish Bista MWRHD Surkhet

Satya Acharya MoHP

Shambhu Raj Baral BNMT Shankar Raj Lamichhane IOM

Sharmila Baral Himal Hospital

Shaurabh Sharma CBM

Shela Sameuls HERD Shobhana Gurung Pradhan BNMT

Shovana Rai NSI

Shyam kandel HERD

Shyam Shrestha WideVision Media

Shyam Sundar Nepal SPAN/JGSS

Soma Rai BNMT

Subash Thapa Nobel College

Sumit Karn Save the Children

Sumnima Shrestha BNMT

Sunil Basnet HOPE College

Sunil Mishra Tri-Chandra College

Sunil Shrestha SMNF nepal

Suraj Pariyar SADG

Surya Prasad Koirala MoHP

Sushila Belbase HRH Alliance, Kapilvastu

Tek Bahadur Khatri MoF

Tek Raj Pandey BNMT

Tekendra Deuba HRH Alliance, Doti

Tirtha Kumal BNMT

Tracy Ghale WHR

Tulasi Ram Gurunng MoHP

Tulsi Bhattari MoHP

Umesh bhushal Save the children

Umesh Kumar Sah BHORE, Janakpur

Upendra Dhungana MoHP

Uttam K. Shrestha MoHP

Vidyadhar Mallik MoHP

Vijaya Laxmi shrestha Nobel college

Vina Sealam Medic Mobile

Yam Narayan Sharma A/O, MoHP

Yojana Sharma NTV

Yuba Raj Paudel NHSSP

12


proceedings of the - bnmt nepal of national hrh... · message from organizing committee ... role of...

Documents