Pathways to effective surgical coverage in a lower-middle-income country: A multiple methods study of the family physician-led generalist surgical team in rural Nepal.

The Lancet Commission on Global Surgery (LCoGS) recommends using specialist surgical workforce density as one of 6 core indicators for monitoring universal access to safe, affordable surgical and anaesthesia care. Using Nepal as a case study, we explored the capacity of a generalist workforce (led by a family physician or MD general practitioner and non-physician anaesthetist) to enable effective surgical delivery through task-shifting. Using a multiple-methods approach, we retrospectively mapped essential surgical care and the enabling environment for surgery in 39 hospitals in 25 remote districts in Nepal and compared it with LCoGS indicators. All 25 districts performed surgery, 21 performed Caesarean section (CS), and 5 met at least 50% of district CS needs. Generalist surgical teams performed CS, the essential major operation at the district level, and very few laparotomies, but no operative orthopaedics. The density of specialist Surgeon/Anaesthesiologist/Obstetrician (SAO) was 0·4/100,000; that of Generalist teams (gSAO) led by a family physician (MD General Practitioners-MDGP) supported by non-physician anaesthetists was eight times higher at 3·1/100,000. gSAO presence was positively associated with a two-fold increase in CS availability. All surgical rates were well below LCoGS targets. 46% of hospitals had adequate enabling environments for surgery, 28% had functioning anaesthesia machines, and 75% had blood transfusion services. Despite very low SAO density, and often inadequate enabling environment, surgery can be done in remote districts. gSAO teams led by family physicians are providing essential surgery, with CS the commonest major operation. gSAO density is eight times higher than specialists and they can undertake more complex operations than just CS alone. These family physician-led functional teams are providing a pathway to effective surgical coverage in remote Nepal.

Medical Scholarships Linked to Mandatory Service: The Nepal Experience.

Introduction: Nepal has one of the world's lowest physician to population ratios, with a critical shortage of rural physicians. The Nepal Government uses the private sector to address this shortage of rural physicians. All private medical colleges must offer total scholarships, free of cost, to a proportion of their annual MBBS student intake. These scholarships come with a compulsory two-year service contract, which must be completed at public hospitals post-graduation. The mandatory service requirement was implemented in 2005/2006 and this paper evaluates the first decade of this scholarship program, with particular attention to the mandatory service requirement. Methods: We collected data on MBBS scholarship awardees from the Scholarship Section at the Ministry of Education, Department of Health Services, and the Ministry of Health and evaluated trends, service completion, and location. Results: Initially, because of poor monitoring, the mandatory service completion rate was low. Rates increased to 74-98% when strict rules tied service completion certificates to obtaining medical registration. In the past 4 years, three cohorts of scholarship doctors who completed their service requirements served 78% of their service-days in rural hospitals (primary healthcare centers and district hospitals). Yet, geographic inequities in physician distribution persist. Only 51% of district hospitals had at least one scholarship doctor, 31% of the district hospitals had more than 1.5 scholarship doctors, while 7% had none. The district hospitals in the Central region, which includes the capital city, had twice the number of scholarship doctors compared to the Mid-western region, which includes some of the country's most remote areas. Conclusion: The scholarship program has partially succeeded in reducing the physician shortage in Nepal's rural hospitals. To address the remaining inequities in physician distribution, efficient management systems, appropriate medical training, and support for rural practice are vital.

A staff support programme for rural hospitals in Nepal.

PROBLEM: District hospitals in Nepal struggle to provide essential services such as caesarean sections. APPROACH: Retention of health workers is critical to the delivery of long-term, quality health-care services. To promote retention and enhance performance in rural public hospitals, the Government of Nepal and the Nick Simons Institute progressively implemented a rural staff support programme in remote hospitals. After competitive selection for a compulsory-service scholarship and training, family practice doctors who could do basic surgery, orthopaedics and obstetrics were hired under a binding three-year contract in each participating hospital. Comfortable living quarters and an Internet connection were provided for the resident doctors; in-service training for all staff and capacity development for each hospital's management committee were provided. LOCAL SETTING: Nepal's mountainous landscape, poverty and inequitable rural/urban distribution of health workers pose barriers to adequate health care. RELEVANT CHANGES: Between 2011 and 2015 family practice doctors were maintained in all seven programme hospitals. All hospitals became providers of comprehensive emergency obstetric care and served more patients. Compared with hospitals not within the programme, deliveries increased significantly (203% versus 71% increase, respectively; P = 0.002). The programme recently expanded to 14 hospitals. LESSONS LEARNT: A package of human resource supports can improve the retention of doctors and the use of remote hospitals. Factors contributing to the success of this programme were compulsory-service scholarship, central personnel management, performance-based incentives and the provision of comfortable living quarters.

Career choices and what influences Nepali medical students and young doctors: a cross-sectional study.

BACKGROUND: Nepal, as a nation with limited resources and a large number of poor people, needs far more well-trained, committed general practitioners. The aim of this study was to understand medical career choices and the factors that influence medical students' and young doctors' career choices in Nepal and to understand what would encourage them to work in rural areas as generalists. METHODS: This was a cross-sectional study of 1137 medical students (first and final year) and young doctors (interns and residents) from six medical colleges in Nepal who completed a voluntary questionnaire, with some also participating in structured focus groups - 170 first years, 77 final years and 80 graduates - with an additional 28, 44 and 49 written responses respectively. RESULTS: Without selective admissions policies, 41.7% (464/1112) of respondents had a rural background - most significant in Year 1 students, males and in colleges outside of Kathmandu. Of the respondents, 569 (50.9%) had a specialty choice starting medical school - the greatest proportion in Year 1. Medicine (especially cardiology) and surgery (particularly among males) were most significant choices at all stages. Only five participants initially and four during their course chose general practice. There appears no interest in, recognition of, significant exposure to, or role models in general practice.Serving the sick, personal interest and social prestige were the most significant influencing factors - consistent across all groups. Course availability was also a factor. To attract doctors to work in rural areas most respondents affirmed the need for a good salary, infrastructure and facilities, scholarships and career development opportunities. CONCLUSIONS: Challenges include raising generalists' profiles within the medical community, government and patient community; changing undergraduate curricula to include greater exposure to good models of rural generalist practice; and providing incentives and attractions for post-graduate training and service.

Medical students' characteristics as predictors of career practice location: retrospective cohort study tracking graduates of Nepal's first medical college.

OBJECTIVE: 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. DESIGN: Observational cohort study. SETTING: Medical college registry, with internet, phone, and personal follow-up of graduates. PARTICIPANTS: 710 graduate doctors from the first 22 classes (1983-2004) of Nepal's first medical college, the Institute of Medicine. MAIN OUTCOME MEASURES: Career practice location (foreign or in Nepal; in or outside of the capital city Kathmandu) compared with certain pre-graduation characteristics of medical student. 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, 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.