Nursing grievances against the state

Nepal has an over-supply of nurses, but nursing positions at hospitals are vacant because of low pay and overwork

A nurse after delivering a baby in Udaypur in Nepal. Photo: NARESH NEWAR

Ritu got her nursing licence in 2017 and started working at a hospital in Bansbari for a monthly salary of Rs15,000. She had a heavy workload, had no overtime pay and could not always get a day off.  

Two years into her job, Ritu’s brother fell ill and she took two days’ leave to go to Pokhara to care for him. Nursing her sibling back to health took her two additional days, and when her hospital demanded clarification Ritu was so outraged she quit.  

Ritu then approached another clinic, where she had to work two weeks as a trainee without pay. After that she was offered a salary even less than her previous job. She was so overworked, she left that job after three months even though she had got only a month’s pay check. 

Ritu went back home to Pokhara and has been out of work for six years. Her mental health has deteriorated during this time. She told Nepali Times: “Experiencing the exploitation and abuse makes me want to tear up my nursing certificate.”

Puja is another Proficiency Certificate Level (PCL) nurse from Nepalganj who got a job through a recruitment office that paid only R12,000 a month. Her middle-income family is in debt after spending Rs1.2 million on her nursing education. Puja reluctantly accepted the job, which was harrowing. 

There were only seven nurses in the 50-bed hospital, and Puja had 18-hour shifts with no overtime. She quit after a year, and has been without a job at home in Nepalganj for the last six months. “Becoming a nurse was a dream that turned into a nightmare,” she told us by phone.

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Anjali Pokharel from Dang got the same nurse job in the same hospital as Puja, but she was offered only Rs11,000. Her monthly hostel rent in Kathmandu alone was Rs12,000. 

“There is no earning, respect, or professional satisfaction in nursing,” says Anjali. “I never  imagined that the nursing sector in Nepal was so bleak.” 

Another nurse with a decade of nursing experience is working at Ihsan Children’s Hospital in Kathmandu for Rs18,000, and says she was threatened with dismissal when she spoke out about low pay and overwork. She told us confidentially: “Despite great dissatisfaction, nurses are forced to keep working because there is no other choice.”

All 20 nurses Nepali Times spoke to for this story said they were subjected to exploitation at their workplaces. Says a nurse currently at Norvic Hospital in Kathmandu: “Most nurses fall ill due to the workload, and many speak of wanting to go abroad for more respect and money.” 

For Nepal’s aspiring nurses, exploitation begins in the classroom. While the government has set a fee of Rs475,000 for the post-SEE three year PCL diploma course, many nurses spend up to Rs1.5 million to complete the course. The four-year BSc nursing fee is capped at Rs750,000, but nursing colleges set fees as high as Rs2.2 million, tacking expenses for food, accommodation, educational tours, etc. 

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Female students are also subject to harassment and disciplinary practices that put restrictions on how they can dress, as well as how they do their hair and make-up.

Nurse training itself is book-based with outdated curricula, and many nurses will not have interacted with actual patients throughout their academic career. Seema KC, who works at the Civil Hospital in Bhaktapur, says that the lack of practical knowledge means nursing graduates are incapable of the real-world working environment. 

This is one reason why even the country’s largest, international-level hospitals keep new nurses on probation at very low wages. The government also does not have a fixed minimum wage for nurses, a loophole private hospitals have taken full advantage of.

Nepali Nurses in UK
Nepali nurses working in the UK. Nurses have started leaving Nepal in search of better professional and academic opportunities abroad.

A nurse interviewed for this story said she had been offered merely Rs4,000 at Megha Hospital despite having had previous work experience, while Norvic pays PCL nurses up to Rs16,000 and nurses who have a Bachelor’s in Nursing Science (BNS) Rs25,000.

Although working hours for nurses at private hospitals are supposed to be only six hours, many work for twice as long daily. The Nepal Health Service Regulations stipulate that health workers should only work 40 hours per week, and are entitled to compensation and additional service leave if their working hours are extended beyond the set hours.  

Salaries at government hospitals are better compared to private hospitals, but nurses are reluctant to work there because of lack of opportunities for career progression, and are forced to tolerate lower pay at private hospitals.

Exploitation, low pay, high nursing college fees, lack of academic or professional growth are driving Nepal’s nurses overseas in droves. 

“Most nurses at Teaching Hospital have decided to go abroad because there are more academic and professional opportunities outside Nepal,” says Sarita Poudel, a nurse there. Government hospital directors say three to five nurses resign every week, some to pursue nursing abroad, and some to leave the sector entirely. 

Read Also: Nepali nurses now Britain-bound, Radha Adhikari

Nepal’s Department of Labour granted work permits to 40 nurses to go abroad in 2013. This number increased to 160 in 2019, 109 in 2020, 287 in 2021 and 582 in 2022. In 2023, 607 nurses received permits to go overseas.

However, many nurses who go abroad do not appear in these official statistics. Some have gone abroad on student visas to study other subjects. A nurse working at Vayodha Hospital says she is going to Canada on a non-nursing student visa, adding that she will need nothing more than her Nepali nursing license to sit for the nursing license exam there.

Data from the Ministry of Health and Population states that there are 14,099 vacancies for nurses across the country, while there are only 9,951 nurses currently employed. The shortage of nurses is affecting medical care across Nepal. In government hospitals, the nurse-patient ratio is 1:40.

The Health Institution Operating Standards stipulates one nurse for four to six beds in the general ward, one nurse per two beds in emergency and postoperative rooms, and one nurse per bed in ICUs and CCUs. Meanwhile, there must be two Skilled Birth Attendants (SBA), trained nurses or midwives per patient in delivery rooms. None of Nepal’s hospitals – private or government – meet this requirement.

Bir Hospital alone requires at least 938 nurses for its 550 beds, but only 400 are currently employed. The 350-bed Kanti Children’s Hospital requires 600 nurses but has only 169. It is even worse at the Prasuti Griha maternity hospital which needs at least 735 nurses but only has 154. 

The minimum service standards of the Health Ministry means Nepal’s government hospitals alone need 32,000 nurses, but have only half that number. The irony is that while the nursing posts remain vacant, many nurses are unemployed.

The Ministry of Health’s Nepal Health Workforce Projection, (2022-2030), states that Nepal had produced 72,550 staff nurses until 2021. Excluding those who went abroad or had retired, 50,785 staff nurses were available against an estimated requirement of 39,249 professionals. This means that Nepal should theoretically have an excess of 11,536 staff nurses.

According to the report, Nepal will need 43,056 nurses by 2031, including 22,255 who have completed the Auxiliary Nurse Midwife (ANM) diploma course as well as 240 graduate nurses and midwives. There are currently 115,793 registered staff nurses and ANM professionals in Nepal.

Meanwhile, new nursing colleges are mushrooming with little regard to meeting accepted standards. They produce 7,000 nurses every year, but few get jobs overseas because they are not deemed qualified enough.

The Ministry of Health in 2012 gave medical colleges a deadline until 2016 to build their hospitals of up to 100 beds to employ graduating nurses, but most never followed this directive even after multiple deadline extensions. In response, the Medical Education Commission stopped admissions to institutions that did not have 100-bed facilities, but colleges have been lobbying to be allowed to teach students without meeting those standards.

The Nursing Association of Nepal has forced the government to agree to reforms in the sector, but few of those agreements were ever implemented. Nurses who spoke with Nepali Times said that many of their problems would be solved if the Nursing Association of Nepal and the Nepal Nursing Council took more initiative. 

Mana Kumari Rai, president of the Nursing Association blames the Health Ministry for failing to meet past commitments. Last week’s government change has again brought in Upendra Yadav of the JSP as health minister, but few nurses have hope that things will change for the better any time soon.  

Some names have been changed.

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