Nepali nurses gone and going to the UK

This is the 39^th instalment of Diaspora Diaries, a regular series in Nepali Times with stories of Nepalis living and working abroad.

Binod Simkhada 

I have lived in the UK since 2004. My years spent abroad have started to outnumber the years I have lived in Nepal, and I find myself facing an identity crisis.

I feel like an outsider in Nepal except when I am at home with my parents in Balaju. Yet, I am still not British enough in Britain. Most of my non-working hours are spent with Nepalis in the UK, talking about Nepal and reminiscing about growing up back home.

Read also: Nepal's nurse flight, Editorial

As a male nurse, I am in the minority in my profession, and patients often mistake me for the doctor when working with a female physician. This has become even more common as my hair goes grey.

I did not intend to study nursing when I first came here from Nepal as an 18-year old. My sister and wife are also nurses in the UK, and I once served as president of the Nepalese Nursing Association UK (NNAUK) that promotes the welfare of Nepali nurses in Britain.

Nepali nurses who come to the UK these days are much better informed, aware about the benefits and rights of the job, and have aspirations to rise through the ranks. 

Before coming, they weigh their options against other countries like Australia and the US. They are not here arbitrarily just because it is the UK. Work can be demanding with 12-hour shifts, little assistance from staff and lots of mandatory documentation.

I am glad that the Nepal government has signed a bilateral deal with the UK (see report below) as it is rare for Nepal to even contemplate a managed migration scheme for skilled workers. 

But even without the agreement, nurses have been coming to the UK individually. As Nepal is in the WHO’s Red List of countries with a fragile health system, British employers cannot proactively recruit Nepalis and deprive their home country of trained healthcare staff. But nurses do apply, and come on their own.

Read also: New UK job options for Nepalis, Upasana Khadka

Retention of nurses in Nepal, especially in remote underserved areas, is a persistent problem because of low benefits and poor facilities. 

How can we call it a job when a nurse working even at a private hospital earns only Rs15,000 a month? This is barely enough to survive. The salary structure of healthcare workers in the private sector in Nepal needs to be regulated and policed.

There are many unemployed and under-employed nurses in Nepal, and allocation of nurses rather than shortage is a bigger problem. In fact, the supply of nurses increases when opportunities for foreign employment opens up, and youth choose job prospects abroad.

Nepal needs to also rely more on its diaspora. My whole organisation was behind me during the 2015 earthquake when others in the British National Health System (NHS) including those who didn't even know me extended their spontaneous support.

I was not in Nepal nor was my immediate family affected in the earthquake, but we all came together as Nepalis to help. NNAUK continues to support Nepal, including the establishment of a birthing center in Jumla that was recently handed over to the local government. One does not need to be in Nepal to contribute to Nepal.

Purnima Ghimire Huumagain

I arrived in the UK six months ago and went through the same process as the UK-Nepal government-to-government deal for nursing staff, but I did all the job hunting on my own. I did not apply through an agency, so I was not swindled like many others are. 

I had passed Nepal’s civil service exam and had relatively better pay and stability, yet I decided to leave. At a health post in rural Lalitpur, the position itself was politicised. 

Read also: Saving Nepali mothers on Mother's Day, Naresh Newar

Transfers were at the discretion of local officials and there was no respect and appreciation nor proper growth opportunities. Transfers also overlooked considerations like whether you are a new mother, which I was.

Respect for nurses is sorely missing in Nepal, even though the health system would collapse without us. We work in under-equipped and under-funded health posts and still are not appreciated or paid adequately. 

In 2017, I withdrew an offer to study in Australia because I wanted to serve my country. Somewhere down the line, that urge dissipated, and frustration took over. 

When I first started working in the UK, everything felt new, and I had difficulty understanding the foreign accent. Perhaps my apprehension was evident on my face one day when on a palliative case an elderly, kind patient noticed and asked if I was nervous. I said no. A month later he was admitted again, and remembered me. He complimented me on how I looked much more confident than the last time. 

And I do feel more confident. I am learning new things every day. A few weeks into the job, I got an email from my manager thanking me for my work that day which had been quite stressful. I was pleasantly surprised. It is these little things that matter.

Back at the health post in Nepal, one day I received a call from a patient who needed a cesarean that was not available at my health post. As there was no ambulance readily available, I had arranged for a truck to rush her to hospital and she called to thank me after her delivery. Very different contexts, but it is the same feeling of being appreciated that is most important.

Read also: Another baby's life saved in rural Nepal, Naresh Newar

Earning more is just one aspect of working here. Options like nursing are good for people who prioritise learning and career growth. If the expectation is solely to earn, that will not happen. We get carried away converting our salaries into Nepali rupees, but living costs here are high.

We got a raise in June following strikes staged by the Royal College of Nursing in the UK to protest insufficient pay. My savings are modest, but as my husband will soon be joining, it will be easier to save. 

I am excited about my husband and daughter joining me in a month or so. I cannot wait to hug them at the airport.

Shradda Karki

I have been a professional nurse in Nepal for the last seven years. 

I was primarily involved in the maternity section. The best part of my job has always been handing over a newborn to the mother after delivery. 

At that moment, all is forgotten by the emotional mother including the excruciating pain she just endured. It is easy to get attached to a job that allows me to be part of such moments of bliss. 

However, I resigned a few days back. I am headed to the UK to pursue further education in healthcare management. Nursing in Nepal has three main problems as I see it that need to be fixed: lack of respect, high patient to nurse ratio, and low salary.

Even after seven years as a nurse, I make Rs34,000 a month which is still better than what many other nurses earn but is not sufficient considering the amount of work I put in, rising costs and high tuition fees. There are 44 beds in my ward, and just two of us. What I like about my job the most is patient care but the workload seldom gives me a chance to really connect with my patients. 

I chose a degree in the UK because it will open new opportunities for me globally. Most of my classmates are now abroad. On balance, things are significantly better abroad for the same level of effort I put in here. 

Read also: Nepal's rural lifeline, Sonia Awale

In the last two months, four colleagues have resigned and gone abroad. Those who have not are already preparing for language tests, and getting documents together for visa applications. 

I am aware of the struggle that awaits me overseas, but I am prepared for it. Hopefully, there will be a sense of fulfilment from the higher earnings, better growth and learning opportunities. 

Diaspora Diaries is a regular column in Nepali Times providing a platform to share experiences of living, working, studying abroad. 

Authentic and original entries can be sent to [email protected] with Diaspora Diaries in the subject line. 

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Nepali nurses don’t wait for UK deal to migrate 

Supply-demand rules govern Nepal-UK agreement to provide nurses to the NHS

From 20 July, the Nepal government and UK have started accepting applications from nurses under a bilateral government-to-government (G2G) mechanism signed last year. In this pilot phase, 100 nurses are expected to benefit from zero-cost recruitment and receive equal treatment as other nationalities including benefits, rights and protection.

But Nepali nurses are not waiting for this agreement to be implemented, they are already migrating on their own to Britain and elsewhere in large numbers (see adjoining Diaspora Diaries above).

Nepali Times spoke with nurses in Bhairawa, Kathmandu, Saudi Arabia and the UK who are applying to go overseas, are current migrants, and returnees. Nurses are in high demand in many industrialised countries and there is a severe labour crisis in the healthcare sector globally.

The Nepalis, mostly women, have various reasons for choosing a specific destination country. A friend, a relative, or ease of migration. Three of our respondents complained that Australia’s paperwork is too cumbersome. The UK allows faster track for registered nursing. Japan has strict language requirements. Both preparation and testing costs for exams like OET (UK) and NCLEX (US) are high, others said.

And if all else fails, UAE and Saudi Arabia also offer good pay and are attractive transit destinations before they apply elsewhere to countries that offer permanent residencies. In addition, there is also demand from Israel for Nepali nurses and caregivers.

It is as if the nurses are all saying: anywhere but Nepal.

Purnima, a UK-based nurse, says that among her batchmates of 40, 26 are in Australia, six in the UK, three in the US and one in New Zealand.

In Bhairawa, lab technician Rita is headed to Canada for her studies. Despite being a scholarship student, she does not want to apply for jobs in hospitals, not just because of the low salary but also because she knows that her better networked peers will have a head start.

Rita did a six-month unpaid internship in Nepal when she had to cover her own expenses despite working long hours. She says, “I know I entered this field to provide selfless service but when you have an uncertain future in Nepal, you do feel the urge to rush to find a way out.”

She has already got loans worth 15,000 Canadian dollars, and knows it will not be easy to pay it back along with next year’s academic fees, but she hopes her effort will be rewarded ultimately.

Another Kathmandu-based nurse says, “After ten years working as a nurse here, I decided to call it quits.” She is now studying for her PTE because the Occupational English Test (OET) that is required for nurses in the UK was both too difficult and expensive. She plans to apply for a senior care position in the UK which will be easier than applying as a registered nurse.

“I earn Rs50,000 a month in my semi-government position but somehow, when everyone leaves, you too start feeling like you are missing out by staying back,” she confides. “I am shocked that the allowance for overnight duty is only Rs150 here.” 

However, a UK-based nurse told us that it is not all a land of milk and honey overseas. Senior care workers, in particular, are vulnerable to abuse by fraudulent agencies and charge high recruitment fees and delayed job placements in elderly care homes.

Nurses who are not leaving for countries like the UK, US and Australia are headed to Saudi Arabia and the UAE. A Dammam -based nurse told us on the phone: “There is no comparison between working in Saudi Arabia versus Nepal. I had to do a full-time job and a part-time job to make a total of Rs23,000 a month in Nepal. Here, I am saving Rs100,000 a month with all living expenses covered.”

She adds that exposure to new technologies and the training in topics like infection control make nurses more competitive in the job market. For many Nepalis, the Gulf is a transit as they prepare for the IELTS, OET or NCLEX on the side, save, and get the required work experience so they can apply via consultancies based in the Gulf itself to go further afield.

With or without the Nepal-Britain deal, nurses continue to follow the money, convenience, and new opportunities overseas. Brexit and the end of free movement of EU nationals has further increased the shortage of nurses, but the rise in migration has nonetheless sparked public discussions in Nepal and the UK.

Public attitude surveys show strong support for an increase in overseas workers in the UK in several sectors including nursing. Binod Simkhada, a UK-based nurse who formerly headed the Nepalese Nursing Association UK, says international recruitment in Britain is also viewed by some activists with criticism as a “quick fix” rather than a long-term solution to the severe healthcare professionals shortage there, and there are calls for the National Health Service (NHS) to invest in UK-trained healthcare workers instead of just relying on international recruitment to fill shortages.

But the UK is struggling to meet its student nurse recruitment targets and has also seen large volumes of leavers who quit service for various reasons including high pressure and poor work-life balance.

Simkhada recognises that better managed legal pathways like the G2G pilot can promote ethical and well-managed recruitment, preventing Nepali nurses from looking for backdoor entries with student visas that are expensive. He says skilled emigration is a positive net gain for Nepal.

Critics are not so sure. They say the UK’s gain would be Nepal’s loss. Britain, they say, is “stealing nurses” from countries with fragile health systems. They also say nurse salaries in the UK under the G2G deal that are considered high by Nepali standards should address the high living costs there.

Nepal is one of the 55 countries in the WHO health workforce support and safeguards list that are facing the most pressing health workforce challenges related to universal health coverage including a density of nurses below the global median.

The UK’s own Department of Health and Social Care has listed Nepal in the Amber List since 2022 with the government piloting managed and ethical recruitment of healthcare workers while prohibiting other organisations from actively recruiting from Nepal. WHO says G2G deals with countries like Nepal should also specify benefits to the health system of source countries that are ‘commensurate and proportional to the benefits accruing to destination countries’.

This is also echoed in calls for Britain to help countries like Nepal with weak health infrastructure that are essentially subsidising the UK health system by sending their trained workforce. Countries like the UK should consider going beyond traditional labour agreements to mutually beneficial skills partnership models that would also benefit the health training and infrastructure of migrant origin countries. The UK-Nepal model can serve as an important platform in making overseas migration better.  

A UK-based Nepali nurse said, “I seriously doubt that there is a shortage of nurses in Nepal, but I hope the perception of shortage ensures that the government and employers address the rock-bottom wages, lack of respect and mentoring, and poor working environment for nurses in Nepal.” 

Simkhada adds, “There are already many unemployed nurses in Nepal. Allocation rather than shortage is a bigger problem at the moment.” He notes that the supply of nurses in fact increases when opportunities for foreign employment opens up, as youth choose fields of study with job prospects abroad. Indeed, there is widespread dissatisfaction about the working condition and payment of both public- and private-sector healthcare workers and many just view it as a springboard for overseas opportunities, as nurses collect the required work experience or buy time to prepare for overseas jobs. Resignation letters are handed in with little or no remorse.

 The UK itself is also facing criticism for the working conditions of its nurses. Nurses have been staging strikes over pay disputes, especially given the cost-of-living crisis in the UK that has left them struggling. In response, the government has recently agreed to a 5% pay rise to last year’s salary and a one-off lump sum amount.  

The sorry state of employment conditions of health workers in Nepal diverts attention from the challenges experienced by nurses working abroad to integrate, work and make the most of their overseas opportunities. But as Nepali migrant workers overseas point out, at least nurses abroad benefit from career growth and higher earnings that they invest in their children’s future. In Nepal, they just struggle alone for low pay and little appreciation.