Nepali Times
Why some doctors stay and others go away

The most serious problem with Nepal's healthcare system isn't just that there aren't enough hospitals, but that there aren't doctors even in the hospitals that exist in remote areas.

Nepal's ratio of doctors to patients is improving, but is still the worst in Asia: there are only two doctors for every 10,000 population, compared to 60 per 10,000 in Cuba. And even these doctors are concentrated in the cities.

Retention of qualified medical staff in rural Nepal has always been a problem in a country where most doctors and nurses either migrate to the capital, or go abroad.

The reasons are fairly obvious: better pay and facilities attract doctors who have to recoup the huge investments they make in financing their medical education.

Now, a new study by a group from the Kathmandu-based Nick Simons Institute (NSI) published in this week's British Medical Journal analyses data of the graduates of the Tribhuvan University's Institute of Medicine to find out what makes a Nepali doctor practice in rural Nepal instead of moving to Kathmandu or migrating abroad.

The study has looked at criteria like gender, age, birthplace, or pre-medical education of 436 of the 727 graduates of the Institute between 1983-2004 to see if there is a pattern in their decision to serve in rural areas. The study found that 27 per cent of the graduates worked outside Kathmandu, 37 per cent practiced medicine in Kathmandu and 36 per cent of the doctors had gone abroad. Of these, three-quarters were in the United States, eight per cent were in the UK, with the others scattered in Australia, South Africa and other countries.

'Doctors graduating in later years were more likely to practice in foreign countries and less likely to practice in rural Nepal,' the paper states, adding that male students made up 88.3 per cent of all graduates and were more likely to remain in Nepal and work in rural areas than their female classmates.

The research paper was prepared by the NSI's Mark Zimmerman, Rabina Shakya, Bharat Pokhrel, Basista Rijal, Ritendra Shrestha and Arun Sayami of the Institute of Medicine and Nir Eyal of the Harvard Medical School.

The findings also show that 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. Also, medical students whose grades were in the lowest third of the class were doubly more likely to be working in rural areas than those with higher marks. Medical graduates born in rural areas and older graduates were both more likely to stay in Nepal and work in the districts.

'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 schools,' the report concludes. 'Selecting students with this background does not guarantee eventual rural practice, but it seems to increase the likelihood.'

Although the proportion of Nepali graduates of the Institute of Medicine who migrate abroad is quite high, things are not as bad as in Ghana where three-quarter of all graduates leave the country after graduation. The paper shows that putting more emphasis on rural birthplace, rural education and a paramedical background rather than on high entrance scores in medical school exams may favour retention of doctors in Nepal.

The government's Institute of Medicine was set up in 1978 to train doctors to serve in the remote rural areas of the country. However, over the years with the advent of private medical schools the emphasis has changed.

Although set up before the NSI study came out, the Patan Academy of Health Sciences (PAHS) has been trying out a novel approach to ensure that its graduates serve in the districts by changing the philosophy of its curriculum.
Sixty per cent of those enrolled in the batch that will be graduating in 2016, for instance, are from underprivileged families mainly from rural areas. Their scholarships require them to work for two to four years in the districts during medical school. If they don't, they won't get to graduate.

The students will be posted to remote area hospitals every six months for two weeks each so they get over their fear of the unknown, and get to see how they can make a difference right from the start of their training. PAHS hopes that this will improve retention of doctors in rural Nepal.

PAHS selects 60 students from over 2,000 applicants, choosing those with personal qualities that ensure more compassionate and empathetic physicians will enter the public health system. Private and government medical schools produce 1,500 doctors each year, but half of them migrate overseas and the ones that stay choose to work in urban areas.

Kunda Dixit

Read the full report of the NSI study in the British Medical Journal


More than a third of the doctors who graduated from the government's Institute of Medicine now work abroad. Breakdown by country:

188 United States
20 United Kingdom
8 Australia
8 South Africa
7 China
4 Canada
4 Japan
2 Bangladesh
2 India
2 New Zealand
2 Sweden
9 Others

Read also:
A nation's health, EDITORIAL
Selecting medical school applicants with district backgrounds and who have worked their way up as paramedics improves chances of doctors serving in rural Nepal

In an ailing state, ANURAG ACHARYA
If this is the state of city hospitals, imagine what it is like in rural areas

Public participation in public health, BHRIKUTI RAI in KAILALI
Communities in western Nepal act to improve local governance and healthcare

See also:
Missionary zeal, MICHAEL COX
New Nepal medical school aims to motivate students to serve in rural areas

1. dr manohar budhathoki
I think this was a good piece of research. One other obvious fact is- the doctor's knowledge of English language. If the doctor's English is poor, he is less likely to emigrate. I did my MBBS in Calcutta and my classmates there came from rural West Bengal mostly. They did their +2 studies in Bengali and not in English (unlike in Nepal) and most of them had poor English and among my batch mates, those with good English (from the cities like Calcutta, Delhi, etc.) have emigrated to USA, UK and the majority with poor English have stayed behind. Of course through facebook, I know who among my batch mates is where!

One important research has shown that emigration of health workers actually helps their native country. How? Not only from the remittance they send back! Because of the attraction of moving abroad after graduation, many talented people take up health care studies. Obviously, most of them can not move abroad and end up working in their own country. I believe this is the case in a lot of health personnel. Many of them in medical/nursing schools are working hard and hope to emigrate but ultimately, most of them will end up working in Nepal. I agree with what this research has shown up but I guess I want to tell readers there is other sides to this story.

2. Dr Dilip Kumar Yadav
In part, I agree with Dr Budhathoki that when young students see the attractive lifestyle of doctors who have moved abroad, more people take up medicine as their career and since only some of them will be able to emigrate to developed countries eventually, the rest of them will stay back to serve in their own  countries. No doubt, English is also a very important factor that play  very good part in confidence and eventually success in emigration of these doctors.

But I believe something else. I think that in modern context when world has become like a small village due to advancement in communication, transport and various other sectors, every doctor is an international commodity now. They should be utilized wherever they fit optimally. The issue of nationality in field of health sector is not justified. A doctor, who may have a great aptitude to develop new medicines and find the cure for AIDS for example, should go where research for this is possible, and should not be taught the lesson of nationality and hypnotized to work in the rural areas throughout his life. That will eventually be a great recession to the field of  medicine and human civilization. A very qualified doctor cannot and should not limit his service to a rural area with very limited equipment. If he feels satisfaction in working in these rural area, for example Dr Govinda KC, that is again, totally a different story. But I am against the view that policy maker should change the criteria for selection of students to study medicine just because they are not going to the rural areas to serve. This may bar the students with real capability and aptitude for medicine to enter into this field, and in long term, will help reservation policy to flourish. 

I feel bad when service to others is done by force or  by coercion. Feeling of service should come from within. Doctor should enjoy what he is doing. If he enjoys serving in a developed country that should be fine. After all he is serving the humanity and earning money which he can help his countrymen in other ways like building hospital in his villageand paying a doctor who enjoys working in rural areas. Being a doctor from Nepal doesn't mean he should be forced to work in a rural environment if he doesn't enjoy that. If he finds joy in neurosurgery and plastic surgery, he is still serving his community but at different level. There are doctors who were trained in developed countries but find satisfaction in serving people in poorest of countries and facilities like African nations and Nepal's rural area. How will they feel when they are told to serve in their own countries and not to emigrate. How if policy maker in their country do not select them to be doctors because that is a loss to their nation's investment? Will it not be like breaching their freedom ?

When natural flow of anything is intervened, then that is going to build pressure unsought of. Policy makers should not be short sighted to change things in name of hypnotizing people to give kinds of service which they may not at all enjoy. Doctors from both developed and poor countries emigrate to seek satisfaction in their life and that is all very natural.       

3. Dr Sailesh Shrestha
I feel that most of the doctors from Institute of Medicine working in Nepal at present are from older batches.Those with paramedical background are not allowed to practice abroad as they do not have plus 2 /ISC degrees.Perhaps that is the reason they are working in their own country at present.

4. Yesme
If remote villages of Nepal were equipped with modern medical facilities,  good cafes and restaurants, malls and big cinemas, a sleek road for a sleek cars, 24/7 convenience stores, good and efficient bureaucratic system, non-threatening and relaxed way of lifestyle stripped off of house-bounding rituals and traditions then of course doctors would pull each others leg to get into that village! Reality is different. So off to the places around the world where above scenario is a reality!!

The doctors like people of other profession do have the right to choose where they want to stay and practice. 

5. ajiv mishra

hi to all of u participating in this discussion,

first of all i want u all to remind that medicine is a profession n hence we people r other professionals we must enjoy our freedom at work with adequate environment and adequate facility.Everytime we doctors are forced to work at a place n environment which is not suitable for most us.We doctors,also have right to  dream a better life rather working at an unsuited place , forced by  government  or other authorities.Afterall we are serving people whereever we  go.None of us dream to stay in a country like Nepal,where there is minimum facility,poor working conditions,no safety,poor electricity supply,poor transpotation,nonsense and selfish leaders,along with a great political unstability(every under educated leaders has a chance of being a policy maker).Despite this all,most of us  still prefer to work here for our people and nation.I think government must appreciate this, rather criticizing the minority who can't face this chaos and choose to go abroad. U leaders first improve urselves,build a good home(nation) with adequate environment then hold discussion on these points. 

6. Highlander
I agree with Dr. Dilip that doctors should be allowed work wherever they want to and the feeling of serving either the rural or the urban community is up to them. Regarding the fact that doctors are leaving Nepal to work abroad shouldn't be made a big deal since people from other professions also migrate, I have seen pilots leaving Nepal and working for foreign airlines, engineers working in the middle east and many more. Every profession should be treated equally and with respect.

NSI has done a great work by conducting an important research. 

7. Roshan
Let me remind the folks at Nepalitimes and the readers that "correlation does not imply causation". Just because cock crows at the same time the sun rises every day does not mean that the cock's crowing is what is causing the sun to rise. People go to places where they believe they have better opportunities and better shot at a good life. Give them that - if you can - and you fix the root cause of why there are so few doctors serving rural Nepal.

8. Dr No
Whoa, why so sensitive, docs? Guilty conscience bothering you?There are doctors in Dadeldhura, Tansen and Lahan who have served there for 30 years. They are not even Nepali, and they are not complaining about the lack of electricity or shopping centres.  This artcle simply summarizes a research study that looks at where graduates of a medical school that was supposed to produce doctors for rural Nepal are now practicing. It's not trying to make you come back for god's sake. So why all the hand-wringing?

9. Ram Babu
There is a practical side that these letters are not focusing on. The villagers also need docs just like city folks. One of the  objectives of the study may have been to see if this availability  was being achieved or not given all the limitations of Nepali village life and whatever preferences and ideas of freedom that  Nepali docs may have.  

10. Tax payer
Most the IOM students' fees while attending the IOM Maharajgunj campus  have been paid for by the Nepali taxpayer. Perhaps those that have gone abroad without serving Nepal may wish to compensate Nepal in some significant way.
Similarly there are some Nepalis  that went to medical colleges in the US paid for by US sources. These Nepali docs pledged to come back to Nepal and help Nepal. ( Returning to Nepal was the basis on which they were chosen). No one has returned. Perhaps they too could think of compensating Nepal for their good fortune? Perhaps there is an obligation here?         

11. Sunil
The finding that the doctors with paramedic background more likely to stay in Nepal has been quite visible for many years. Similarly, it will not be surprising if engineers with overseer background are found to favor working in Nepal than migrating. These people opted for paramedic or overseer training in the first place because they are self motivated to work for lower pay and in rural area. Hence they are unlikely to need further motivation for working in far off areas even after getting a higher degree. Unfortunately the local universities and Ministry of Education in the pretext of raising the quality, ignore this aspect of human nature.

12. Mark Zimmerman
We did this nonsensical study  because we had a lot of money and wanted to show  something that will help nothing. Having lived in Nepal for so long, I know the Nepal government does not care at all over such issues, neither do INGOs like NSI. but life is moving on and we make money out of all this.

tesaile hamile yesto gareko.

13. Tennessee

Reality does open eyes, maybe not with all, but will do for handful. And I agree that rural community work as part of the curriculum for the college of medicine will serve its purpose. That has been part of the curriculum for decades in the Philippines where 6 months rural service is required prior graduation. On a deeper level, it takes heart and that is why some stay and even foreigners come to underprivileged societies and serve the people regardless of how dire conditions can be. And training the heart to really see the marginalized, the have-nots, the illiterate, even the downcasts starts as early as our formative years in our very own homes.

On a side note, when rural service is proven to be worthy, Nepali doctors, both local or in foreign lands, can mobilize their own contacts: middle class and rich patrons, pharmaceutical companies, NGOs  and even the social welfare ministry to assist in the free or heavily subsidized provision of free medicines plus periodic short term medical missions.

14. Anonymous
Let me thank Kunda jee for bringing this excellent research article to the public's notice. I admire Dr. Zimmerman and many other colleagues  and staff  at the UMN who demonstrated great altruism and dedication for making a difference in the lives of those who came from rural Nepal. Dr. Zimmerman was an excellent medical educator and a physician who understood the reality of Nepal. Over the decades, he has been a close friend of Maharajgunj Campus, Institute of Medicine. UMN Patan hospital was one of the best training sites I ever attended while I was studying medicine at IOM. I am glad to  know that Mark is now contributing in the area of higher policy making in the field of health professions education in Nepal. My experience while working with training grass-root health workers (CMA) in Tansen inspired me to take a career in medical education. (Many thanks to Dr. Harding, Dr. Haug, Dr. Briton!) They were my role-models. I hope someday I will return to Nepal and contribute to enhance the cause of medical education again. Congrats, Dr. Mark!

15. Anonymous
Nepal needs more medical college who produce inferior quality doctors who can't be sold abroad aand hence work in Nepal.

Problem in Nepal is IOM and BPKIHS produce export quality doctors and as doctors are selfish like any other professional they all are exported abroad.

16. DR limbu
i think what patan hospital has done an excellent example to pursue their careers in remote areas of nepal.
Sixty per cent of those enrolled in the batch that will be graduating in 2016, for instance, are from underprivileged families mainly from rural areas. Their scholarships require them to work for two to four years in the districts during medical school. If they don't, they won't get to graduate.
government should invest in such noble institution..
its because now private medical colleges have become  trading centre..more you give money more you chances to get admitted now happening in MD/MS level..
by investing 50+lakhs for MD/MS no one will be willing to work in remote..or just he will be a joke in society..

17. Highlander
Dear Anonymous, I disagree with you for mentioning doctors as selfish. They are no doubt belong to the most learned fraternity of the society but their duty is to serve the patient above everything else. They attend the sick be it Nepal or abroad, that's humanity and you can't label them as selfish. Yes i agree every human is selfish deep within but when it comes to their work and duty, a doctor's profession is by far the most selfless among any other. May be I don't need to mention the tiresome years of medical school training, long duty hours serving the sick and many more.  

18. ms
Here is a simple solution to get more medical professionals in the rural area. Make a 2 year service at a rural hospital, rural health post or rural clinic mandatory  (stipend to be provided by government) after a student takes and passes his fourth year exams and before he/she gets a MBBS degree from Nepal's medical colleges. The colleges themselves could be required to set up health posts in several rural districts where some of their students could serve the 2-year mandatory requirement.  I think they will learn more in the rural area by getting better exposure to a variety of illnesses and situations which will benefit the students themselves in the long run..  The colleges also could use these centers for research on medical issues. With that experience some of students might even decide to practice in the rural area upon graduation.

19. Prakash Gyawali

As a long serving faculty in T.U.Institute of Medicine,I feel the younger generation who are bright choose not to stay back in Nepal as Nationalism & Patriotism are not enough of an incentive compared to the much better facilities and working environment available in Western countries.Too much of corruption,mismanagement and favouritism rampant in our medical institutions can break even the bravest of hearts,if they have alternatives available.Recently,there was an agitation in our institution as well but in the end ,the brother of the former Dean was selected as the new Dean as is well known due to pressure exerted by the former Dean on the Prime Minister and his wife.So nothing new can be expected from the new Dean as well.Moreover,Can he take action againnst his own brother who has helped him to get the post(which was a major demand of the agitation)So MIGHT is RIGHt in Nepal at present

Dr Prakash Gyawali

(11 JAN 2013 - 17 JAN 2013)