The Distribution and Mix of Human Resourcesfor Health in Nepal

1. The Distribution and Mix of
Human Resources
for Health in Nepal
Presented by : Basanta Chalise
MHPE (1st batch)

2. Outline
• Introduction
• Objectives
• Methodology
• Findings
– Pre-service training
– Distribution and shortage of Health workforce
– Mix of Human Resources for Health
• Conclusion
• Recommendations

3. Introduction
• Nepal has been identified by the World Health
Organization as one of 57 nations with a critical
shortage of health workers.
• This creates a huge deficit in the requirements for high
coverage of essential intervention, including those
necessary to met health related MDGs.
• MOHP has also identified major challenges in HRH :
Specially in shortage, distribution and skill mix of
health workers.

4. Objectives
• To analyze the current production,
distribution and skill mix of the health
workforce.
• To provide recommendations to MoHP
and other concerned stakeholders for
improvements in HRH policy and strategic
plans and its implementation

5. Methodology
• A cross-sectional descriptive study was conducted
using mixed method with observation checklist.
• A multi-stage cluster sampling method, Fifteen
districts representing eco-developmental regions of
Nepal were selected.
• 747 health workforce from 375 health institutions were
interviewed using the Probability Proportionate to
Size method as per WHO guideline.
• Observation was carried out in 256 health facilities.
Further, secondary review was carried out for
triangulation of findings.

6. Production (PRE-SERVICE TRAINING)
OF THE HEALTH WORKFORCE IN
NEPAL

7. Production (Pre-service training of
basic level health workforce)
• It includes the production of TSLC level Health
workers
• Primarily produced by affiliated institutions of
CTEVT
• Annual capacity of about 6,500 basic-level health
workers (June 2011)
• Enrolled in 2009 : Only about 3600
• 91,000 basic level health workers were produced
(1993 to June 2011)
• Among them 60 % were CMA and 22% were ANM

8. Production (Pre-service training of
mid level health workforce)
– Includes PCL level course in health science
– Primarily produced by affiliated institutions of
CTEVT
• Current (June 2011) annual capacity of about 8,582
mid level health workers.
• Enrolled in 2009 : Only about 4250
• About 12,355 mid level health workforces were
produced from CTEVT (by June 2011)
• Among them 57 % were PCL Nursing and 22%
were PCL in GM

9. Production (Pre-service training of
High level health workforce)
• Includes Bachelor and above level in Health
science
• Master level:
– Total current annual production:
507( including: MD/MS : 369; MDGP: 20;
MPH: 30 and other)
• Bachelor Level:
– Total current annual production: 3100
( including MBBS: 1255; BN: 499; BPH: 455
and other)

10. Ratio of Health Workers to
Population (Doctors,
Nurses/Midwives)
• The WHO 2006 report shows that in Nepal, there are 7
Nurses/midwives and doctors per 10,000 population
• The latest cumulative statistics of registered personnel from
Nepal’s medical and nursing councils suggest : 16 per 10,000
population.
• The ratio in public sector based upon current sanctioned
position and population census data is only 2.9 health
workers per 10,000

11. DISTRIBUTION OF HEALTH
WORKFORCE IN NEPAL

12. Distribution of Health workers in Nepal
• Latest Cumulative registration data from Medical and
Nursing Councils revealed low ratio of Doctor and
nurses with population than WHO recommended:
Categories
Total Registration
to June 2011
Ratio/10,000
Population
Working in Public
Sector until mid
2010
Medical Doctors 10,753 4 1,628 (15%)
Nursing staff
including ANMs
32,948 12 11,637 (35%)
Total 43,701 16 13,265 (30%)
Total Country
Population
26,620,809

13. Distribution of HRH
(Fulfilled % Vs Sanctioned)

14. Distribution of current HRH
• Doctor:
– Filled: 62% (lowest in hill, PHC and private and NGO run hospital)
• Nurses including ANM:
– Filled: 90% (lowest in Mountain, CDR and I/NGO run clinic or
hospitals)
• HA and AHW:
– Filled 94% (lowest in Mountain, EDR and I/NGO run clinic or
hospitals)
• Technicians:
– Filled 79% (lowest in Hill, CDR and I/NGO and private clinic or
hospitals)
• All cadres:
- Filled 86% (Lowest: Hill, EDR, NGO run clinic and private Hospital)

15. Distribution of all Types of HRH
Cadres in Nepal
• Among the total filled positions,
– the government contributed to 86.7%
– local recruitment (DDC/VDC, I/NGO, private
sector and management committees : 13.3%
• The survey data includes staff recruited through
DDCs/VDCs
– in the Health Posts (9%) and
– Sub-Health Posts (10%), and
• Management Committees, who made the highest
contribution in Hospitals (11%).

16. Distribution of Health workers in Nepal
• Sanctioning positions is not a solution to HRH shortages,
a FCHV from Bardiya said that despite all other positions
in the PHCs being filled, the absence of a doctor was the
major problem in health service provision.
– One FCHV explained that “Doctors and nurses mandated to
perform their night duties are also not found and at night, the
office assistant is found performing the doctors’ duties.”
• Key informants from manager of private hospitals
stated that posts are vacant because of dual practice of
health workforce and there is no job security, no career
opportunities, a high workload and low pay to become
fulltime worker.

17. Skill Mix of Human Resources for Health

18. Skill Mix of Human Resources for Health
• The sanctioned positions are based largely on the
1991 NHP and there is high pressure for all cadres
of HWs to serve an increased population (more
than 45 percent increase since 1991), with an
increased burden of disease and an increased
number of health programmes from central to
village level.
• One of the DPHO from hilly district said that health
workers should have comprehensive training that
covers emerging health problems and makes them
capable of providing a range of quality services.

19. Skill Mix of Human Resources for Health
• The criteria for an effective HRH mix for this survey included
the availability of at least one Doctor, one Nurse/ANM, one
AHW/HA and one Laboratory Assistant in a filled position
and available workforce at the time of survey.
Cadre of HRH Surveyed PHC (n=17)
Government Hospital
(n=14)
At least one Doctor 18% 100%
At least one Nurse 41% 86%
At least one ANM 82% 93%
At least one HA 59% 64%
At least one AHW 82% 71%
At least one LT/LA 77% 93%
Radiographers 50%

20. Skill Mix of HRH at PHC* and Hospital level**
Spatial Characteristics No. of HF Observed No. of HF with a *Mix
of all cadres among
filled post
No. of HF with a *Mix
of all cadres available at
the time of survey
At PHC level*
Mountain 4 0 0
Hill 5 4 1
Tarai 8 4 2
Total 17 8 3
At Hospitals**
Mountain 4 0 1**
Hill 5 3 2
Tarai 5 4 3
*PHC Level: At least one Doctor, Nurse, AHW/HA, LA, in filled position and available at the time of
survey
** At Hospital: At least one Doctor, Nurse, AHW/HA, Radiographer, LA, in filled position and available at
the time of survey

21. The qualitative data from different stakeholders
also mentioned about the issue of Skill mix during
FGD and KII
A Senior District Health Manager from the Hill belt of the EDR stated
in a KII
“…Overall, the sanctioned posts are not enough to give required
health service to the people. The technical human resources are not
enough in the health institutions similarly, the number of available
Laboratory Technicians, Radiographers and staff nurses is very
low…….”.
A journalist from Doti stated that :
“……If the health centre is carefully observed, we will find ANM,
MCHW working in the health centre as doctors, if doctors are really
not available in the communities, community health workers
should be trained properly……..”

22. Conclusion and
Recommendation

23. Conclusion
• The hypothesis that the spill-over effect of over-production of
health workers would positively affect the availability of HRH at
remote service delivery stations has not been realized.
• The uncontrolled growth of private HRH production Institutes led
to relatively uncontrolled production of health workforce including
doctors who do not join the public health sector and often migrate
to western countries.
• Population has increased by 45 percent in the last two decades,
the number of sanctioned positions still based on the 1991 Health
Policy.
• Overall, 14 percent of sanctioned positions for all HWs were
vacant, with a deficit of 38 percent of doctors and a 10 percent of
nurses.

24. Conclusion……
• Greater shortage of health workers in rural health
facilities compared to urban areas
• PHCs and hospitals with a complete mix of filled
sanctioned posts was particularly low in the
Mountain belt compared to other belts, where staff
had to be locally recruited to fill the gap.
• Qualitative data highlighted that absence of one
category of health workers negatively impacted on
the performance of other health workers which
affects health delivery system as a whole.

25. Recommendations:
• There should be strong coordination between the MoHP and
MOE to ensure that HRH pre service training is based on the
needs of the population and addresses the current
imbalance between supply and demand.
• To improve the consistency of HRH data in Nepal, the MoHP
should strengthen the HuRIS covering public, private for-
profit and private not for-profit health facilities. Creating a
database that includes private academic institutions and high
level health cadres should also be considered.
• The MoHP and the respective Councils should strengthen
the monitoring systems for private sector to ensure that
sanctioned positions are filled and there are consistent
quality services.

26. Recommendations..
• The MoHP should encourage the hiring of health workers
at local level through district health system as a part of
devolution considering the local needs, so as to the health
sector partners (EDPs, I/NGOs and private sectors).
• The MoHP should increase the current number and revise
type of sanctioned positions to address the issues of skill
mix and shifting disease burden and population growth.
• The MoHP should create a pool of health staff at the
Regional level who can be transferred to rural health
facilities to fill gaps.

27. THANK YOU