Transformative Education
for Health Professionals

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Nepal's Health Assistants

Julie Orfirer, FNP, Nadia Cobb MS, PA-C

Nepal has a population of 29 million1 with a regional average of 2.1 MDs per 10,000 population and 4.6 nurses and midwives per 10,000.Nepal was on the 2010 the United Nation’s Human Development Report list of 10 nations making the fastest gains in development in the Human Development Index of the past 40 years –although still in dire need of health workers.1 Brain drain and urban private health facilities draw physicians and nurses from the country. This is a case report of two Health Assistant providers who serve in the rural regions of Nepal.

Full project description: 

Two Health Assistants at the Nyapati Community Health Post outside of Kathmandu Center were interviewed for this case. Mr. Jagat Nepali and Mr. Rabin Pokharel are licensed by the Health Professional Council of Nepal under the paramedical category as Health Assistants. Both men described an interest in working in the remote villages with people who had little health knowledge as their impetus toward joining the profession. They have each been dedicated to serving patients for 15 and 18 years.

The Health Assistants received their medical education in a 3 year course. They become certified in general medicine after an examination at the end of their training. They renew their certification every 5 years without repeat examination. Recertification requires one year’s working experience and they are required to take continuing education courses. These tend to be 5-6 days centering on certain diseases or disease classifications. Mr. Nepali recently completed a 15 day training in lung diseases.

Both men work independently under their own license at government run Health Posts. Most posts do not have MD staff. Physicians are usually only consulted in epidemics. There are 63 posts in the Communities of the Kathmandu Valley outside of Kathmandu City proper. Facilities are upgraded yearly. Both men were pleased that in the coming fiscal year the goal is that all posts are due to have a lab and x-ray facilities as well as MD staff. At this time labs and x-rays are not available in the region of the Valley where they work. The closest hospital is in Kathmandu City (approximately a 15 minute drive to the edge of the City). The Health Assistants also travel into the remote villages in the hills to see patients.

The Health Assistants work with a somewhat limited medication formulary. The Health Posts themselves are limited further to a total of 72 items, which includes not only medications but also such items as cotton and betadine. The medication formulary at the Health Posts include only three antibiotics. 

In discussion of the types of health problems that are seen, Mr. Nepali listed skin, GI, and respiratory as the most common. There has been a particular focus on treatment of TB and they’ve had considerable success with a direct observation short course (6 months for new diagnoses, 8 months for relapse/recurrence) where patients come to the clinic daily for medications. He noted that the past few years he has seen the increase in non-communicable diseases such as cardiovascular diseases and diabetes. Mr. Pokharel discussed the issues of maternal problems including pregnancy complications and mortality, a high prevalence of PID and STDs, including HIV. He discussed pediatric jaundice, malnutrition, and diarrheal diseases. They also note a continued dependence on traditional healers that use herbs and other modalities. The teaching at the Health Posts as well as successful programs (such as people seeing cures for TB due to the DOTS program) has increased the trust level of the villagers toward the health care provided by the Health Assistants. Both Health Assistants noted an increase in overall health and hygiene knowledge as well as utilization of their services

References:

  1. http://www.who.int/workforcealliance/countries/npl/en/
  2. http://www.who.int/workforcealliance/countries/Nepal_En.pdf?ua=1
  3. Lehman, U, Mid-Level health workers: The state of evidence in programmes, activities, costs and impact on health outcomes: A literature review. 2008,  WHO
  4. Society for Local Integrated Development Nepal (SOLID Nepal) and Merlin Nepal. Barriers to Effective Policy Implementation and Management of Human Resources for Health in Nepal: The Distribution and Skill Mix of Human Resources for Health in Nepal. Lalitpur, Nepal: SOLID Nepal; 2012  
  5. Knoble, SJ, Pandit, A. Koirala, B., Ghimirie, L. Measuring the Qulaity of Rual-Based, Government Health Care Workers in Nepal, The Internet Journal of Allied Health Sciences and Practice. Jan 2010. Vol8, No. 1

This case study relates to:

Case study addresses:

Quality: 
Yes
Quantity: 
Yes
Relevance: 
Yes
Sustainability: 
Yes