In his commentary Dr Shankar describes the issue of attracting and retaining doctors in rural Nepal1. There is no doubt about relevance of this issue; however, there are some major issues to be discussed with an aim to complete the picture.
There is no one universal definition of a rural area2. In Nepal, Village Development Committees (VDCs) are considered to be rural areas, and municipalities are considered to be urban. The government health system in Nepal does not have any place for doctors below the primary health care center (PHCC) level. There are two government health facilities below the PHCC (Health Post and Sub-Health Post) which are often located in rural areas3. The main problem is that most doctors are urban based and do not serve the rural communities that need them most4. The doctor:patient ratio in Kathmandu is 1:800, while the ratio in the hills and remote areas is 1:30005. The public health workforce is diverse and includes all those whose prime responsibility is the provision of core public health activities, irrespective of their organizational base6.
Dr Shankar only writes about doctors; however, doctors do not comprise the majority of health manpower in Nepal7. These are paramedics such as Auxillay Nurse Midwifes (ANM), Maternal and Child Health Workers (MCHW), Auxiliary Health Workers (AHW) and Village Health Workers (VHW). Nepal has pioneered the successful implementation of community-based public health initiatives by mobilizing Female Community Health Volunteers and peripheral level health workers8. We believe these players are of the same importance as doctors in improving public health in Nepal.
While Dr Shankar rightly points to the importance of the 'brain drain' in Nepal, he only mentions 'push factors' in relation to financial, educational and social support, and does not mention the 'pull factors'9. We believe that unless developed countries seriously re-think this issue, it will be impossible to stop the migration of doctors and nurses from Nepal. It is obvious that Nepal cannot provide benefits and salaries to equal what is available in developed countries. And there are additional factors such as incentives, adequately equipped and organized hospitals, opportunities for career development, and secure working environmental conditions that must also be addressed to minimize the brain drain from Nepal10.
Resesarch has found that the provision of family support plays a significant role in retaining health professionals in Nepal10. The provision of attractive benefits to the family members of health workers who work in rural areas could motivate rural service. Ongoing activities such as the establishment of the Patan Academy of Health Sciences and bonding for doctors who studied with a government scholarship may also help to minimize Nepal's doctor brain drain.
Dinesh Neupane, BHP and Gabriel Gulis, PhD
Unit for Health Promotion Research
University of Southern Denmark, Esbjerg, Denmark
1. Shankar PR. Attracting and retaining doctors in rural Nepal. Rural and Remote Health 10: 1420. (Online) 2010. Available: www.rrh.org.au (Accessed 24 November 2010).
2. Muula S. How do we define 'rurality' in the teaching on medical demography? Rural and Remote Health 7:653. (Online) 2007. Available: www.rrh.org.au (Accessed 8 October 2010).
3. Management Division, Department of Health Services, Ministry of Health and Population. Job Description of Employees. Kathmandu: Government of Nepal, 1997.
4. Ailuogwemhe J, Rajbhandari R, Illiaki E, Villar M, Dieterich M. Tackling Shortages of Health Care Workers in Rural Nepal: 'Train to Retain'. (Online) 2005. Available: http://www.nsi.edu.np/nsi/research/6757Harvard%20MPH%202.pdf (Accessed 9 October 2010).
5. The Himalayan. Number of doctors to double in hospitals.(Online) 2010. Available: http://www.thehimalayantimes.com/fullNews.php?headline=Number+of+doctors+to+double+in+hospitals&NewsID=244059 (Accessed 27 October 2010).
6. Beaglehole R, Poz M. Public health workforce: challenges and policy issues. Human Resources for Health 2003; 1: 4.
7. World Health Organization. Country Health System Profile Nepal. (Online) 2007. Available: http://www.searo.who.int (Accessed 9 October 2010).
8. Arlington VA. Nepal child survival case study: technical report. Partnership for Child Health BASICS II. (Online) 2004. Available: http://www.jsi.com/JSIInternet/Resources/Publications/DownloadDocument.cfm?DBLDOCID=4178&DBLLANGID=3&DOC=Nepal%20CS%20Case%20Study_Tech%20Report.pdf (Accessed 10 October 2010).
9. Organization for Economic Co-operation and Development. Trends in International Migration, p130. (Online) 2003. Available: http://www.oecd.org/document/37/0,3343,en_2649_33931_28703185_1_1_1_1,00.html (Accessed 10 October 2010).
10. Butteworth K, Hayes B, Neupane B. Retention of general practitioners in rural Nepal: a qualitative study. Australian Journal of Rural Health 2008; 16(4): 201-106.