Grass is greener overseas for Nepal's doctors

Migration of physicians leads to a shortage of specialists, weakening a precarious medical system

Sagar BudathokiJan 28, 2024News

In 2009, Samir Lama completed his MBBS and then passed all three stages of the United States Medical Licensing Examination (USMLE), making him eligible to practice in the US. However, he returned to Nepal in a year, opting to serve his own people instead.

Lama pursued a three-year residency in General Medical Practice at the Teaching Hospital in Kathmandu sponsored by the Nick Simons Institute and was later placed at the District Hospital in Piuthan under a three-year contract.

Eventually, at a medical college in Chitwan, Lama’s monthly salary was Rs80,000, a relatively meagre sum for someone with three years of post-MD work experience. Dissatisfied, he established his own polyclinic in Chitwan.

But today, he is based in Britain, working as a resident physician in general practice.

“There are difficulties living and working in Nepal,” Lama tells us by phone. “Becoming a doctor through civil service is difficult, and a physician’s life is financially challenging even in private practice.”
In 2017, Murari Barakoti completed a one-year fellowship in Interventional Cardiology, and preferred to work in Singapore and the Maldives rather than stay in Nepal. He blames the lack of expertise-based remuneration in Nepal for his decision.

“In the Maldives, doctors get ten to twenty times the pay they would normally get in Nepal,” says Barakoti, who is among 1,100 Nepali doctors working in the Maldives today. Ironically, many students from Maldives come to Nepal’s medical colleges for their education.

Sandesh Parajuli, a government scholarship recipient for MBBS in Pakistan, worked for two years at Gandaki Provincial Hospital after he returned. In 2020, he took the medical officer exam at Lumbini Provincial Hospital, and the results are still pending.

Tired of waiting, Parajuli completed his USMLE online and is now in the US. He says, “There is a sense of fulfilment serving patients in my own country, but the working environment in Nepal for doctors is not conducive. Of my 20 closest friends, only one is still working in Nepal.”

It is generally known that young Nepalis are leaving the country by the tens of thousands every year for undergraduate studies in Australia, Canada or Japan. Less well known is this haemorrhage of doctors and nurses.

The depletion of medical personnel has further weakened the country’s already fragile healthcare system, and added to the shortage of specialists. Despite an annual turnover of 2,000 to 2,500 MBBS graduates, Nepal faces a severe shortage of doctors, especially in remote parts of the country.

The Nepal Medical Council (NMC) has nearly 35,000 registered doctors, including 10,588 specialists. But there is no exact figure for working professionals. A 2015 study by the Council reported that approximately 36% of doctors are working abroad, but the actual proportion is estimated to be much higher.

Doctors planning to leave are mandatorily required to present a Good Standing Certificate (GSC), and the Medical Education Commission issued 1,025 GSCs just between April to December 2023. Commission sources say the demand for GSCs has surged in the past four years.

The majority of Nepali doctors have chosen to migrate to the UK, with 1,578 physicians acquiring certificates since 2020. The US is the second most popular destination, with 888 Nepali doctors moving there to practice in the same period. Opportunities in Australia, UAE, Canada, and Qatar are also on the rise.

Sanjeev Sapkota, president of the Non-Resident Nepali Association (NRNA), estimates that of its total membership, 5,000 are doctors and medical specialists. Many others who have migrated have not bothered to become NRNA members. Worryingly, government scholarship recipients make up a rising number of migrant physicians — depriving state-run hospitals in the country of specialists.

Some doctors seek improved working conditions, while others, frustrated with unemployment or exploitation in Nepal’s private hospitals, choose to start anew. They are attracted by the promise of higher earnings, and a better future for their families.

1:150,000

Completing an MBBS degree generally takes six years, and those studying on government scholarships are obligated to work in a rural hospital for an additional two years. During this period, they have no time for further study or to sit for civil service exams. However, once the commitment is fulfilled, they are left without a paying job.

“Despite some incentives for further studies after MBBS, many graduates struggle because of low salaries and uncertain future prospects,” says Shambu Khanal of the Lumbini Provincial Hospital.

Postgraduate study opportunities are also hard to get due to limited annual seats of around 2,000. Additionally, a small number of subject-specific seats further complicates matters, particularly for those candidates below the top 500, barring them from pursuing preferred medical disciplines. Without government support, individuals must bear all expenses themselves, discouraging many more aspiring Nepali doctors from pursuing MD/MS degrees.

This in turn is leading to a chronic shortage of specialists in Nepal. The 'Human Resources for Health (HRH) Projection in Nepal, 2079-2087' reveals a deficit of 5,779 specialists, with the annual production growth rate falling short at 6.41%, thus widening the gap in the doctor-to-population ratio.

At present, there is only 1 doctor for every 850 people in the Kathmandu Valley which is better than the WHO-recommended 1 per 1,000. But this ratio goes down to 1 per 150,000 in remote districts. Despite depopulation of the mountain districts, there is a dire need to retain qualified medical staff in rural Nepal.

The absence of diverse medical expertise, coupled with government oversight of emerging disciplines, leaves returning professionals with no acknowledgment or motivation. The country therefore faces a critical shortage of specialised doctors, particularly in cardiology, surgery, gynaecology, and neurology.

A recent study by the Medical Education Commission showed a shortfall in surgeons: there are only 660 when the country needs a minimum of 808. Medical generalists face a similar deficit, with just 349 working actively against the 1,115 required. The study also foresees a demand for 1,223 medical generalists in 7 years, factoring in population growth.

Doctors in specialised services in new fields face challenges due to inadequate infrastructure and equipment. Even those willing to work in government hospitals struggle to secure positions.

Dharmagat Bhattarai, who is specialising in paediatric clinical immunology and rheumatology, says there is an urgent need for specialised doctors, especially for diagnosing and treating rare diseases in children.

“After MBBS, graduates work as interns in hospitals for a year. Although hospital administrators assign them duties, they do not get adequate compensation,” says Bijay Parajuli, who specialises in pediatric critical care, rheumatology, congenital heart diseases, and neurosurgery.

He adds: “In Pakistan, I received a monthly stipend of Rs44,000 after MBBS while interns in Nepal are getting only Rs9,000.”

Resident doctors pursuing MD/MS face a similar fate. Overworked doing hospital health check-ups, filling prescriptions, and handling ward responsibilities, their studies are often hampered—and all this for poor pay. While countries like the USA, UK, and Canada waive tuition fees for MD/MS programs, resident doctors in Nepal have to struggle for better remuneration.

A government hospital resident earns an average of Rs48,000 monthly. However, those working in private medical colleges are compelled to work for less than Rs20,000.

Some doctors say residents in private hospitals often have to work for 36 hours straight, multiple times a month. Vishad Dahal, an internal medicine student at Kathmandu Medical College, faced suspension for questioning a 20 extra-curricular health camp. His suspension has now been revoked.

NMC’s 'Regulations for Postgraduate Medical Education (MD-MS Programs) 2017' states that postgraduate residents should not be assigned duty for more than 24 hours per week.

Typically, it takes an average of 12 years to complete MD, even after graduation. This means most doctors would not have finished their studies even in their early 30s. Moreover, the cost of private medical education is expensive and often exceeds Rs10 million.

And after all that, there is still no job security, not to mention the years it takes to recover the investment. This prompts many to consider working or studying abroad.

“The rise in Nepali doctors moving abroad demands urgent attention. While it may seem routine at first glance, the trend can potentially cause a scarcity of experts,” admits Shri Krishna Giri, past president of the Medical Education Commission.

He adds: “Restricting doctors from seeking opportunities overseas may not be a practical solution. The challenge lies in finding a nuanced approach that recognises and addresses the multifaceted factors contributing to this exodus.”

With additional reporting by Yugottam Koirala.