A staff support programme for rural hospitals in Nepal

Introduction In remote areas, an absence of doctors and nurses leads to poor health outcomes for local populations. (1) To increase access to health-care workers, the World Health Organization recommends interventions in four areas--education, regulatory, financial and professional/personal. (1) To support retention, WHO and other organizations have called for bundled programmes that take into account health workers' expectations. (2-4) Retention programmes that enhance workers' competence, responsiveness and productivity have also been recommended. (5) Studies on retention of health-care workers in low- or middle-income countries tend to focus on compulsory government service (6) or on salary incentives. (7,8) Few studies have reported on bundled programmes or used patient volumes as outcome variables for such programmes. (3,6,8) Here we describe a bundled programme for human resource support in Nepal. Local setting In Nepal, the mountainous landscape, poverty (the annual gross domestic product per capita is 300 United States dollars, US$) and an inequitable rural/urban distribution of health workers pose barriers to adequate health care. (9,10) Eighty-three percent of 28 million Nepalese live in rural areas. These areas are served by 15-bed public district hospitals, (11) which are expected by the Nepalese Government to provide emergency operations. However, in 2006, only 10 of 64 (16%) district hospitals were able to perform caesarean sections, due to absent, low-performing or mismatched healthcare workers. (12) The support programme To address low retention of health-care workers and poor performance in district hospitals, the Nepalese Government partnered in 2006 with the Nick Simons Institute--a nongovernmental organization working to improve health care in rural areas by supporting Nepalese health-care workers. The partnership developed a rural staff support programme, based on international consensus about retention factors, (1,3) experience in the Nepalese health-care system (13) and stakeholder consultations. The central component of the rural staff support programme was recruiting one or two family practice doctors per programme hospital. These physicians are post-graduate doctors trained in medical universities in Nepal--to provide primary care as well as basic surgery, orthopaedics and obstetrics. To recruit these doctors, we first negotiated with the medical university for three to six seats per year in the post-graduate family practice programme. Then we advertised in newspapers for junior doctors with at least two years of working experience and who had either been raised in or who had previously worked in rural areas. We chose 15 to 20 applicants to take an entry exam. Three to six applicants with the best results were offered a scholarship for the three-year post-graduate programme and binding contracts for a subsequent three years of service in a programme hospital. Doctors who chose to leave the programme early incurred a financial penalty twice the scholarship, which varied from US$ 20 000 --30 000. Once posted in the programme hospital, the doctors received salaries three times higher than the usual basal government rate, not including other government benefits. To facilitate an effective hospital team, the programme also provided personal, professional and management support for all staff working in the hospital (Table 1). The programme was implemented stepwise: In 2007, three hospitals started the programme and in 2009, they were fully operational when scholarship doctors began to graduate from their training programmes. In 2011, four more hospitals joined the programme. All seven hospitals (Bajhang, Kalikot, Doti, Salyan, Kapilvastu, Gulmi and Dolakha) were rural, some were in extremely mountainous regions, and all their districts were below the national Human Development Index mean of 0.471. (14) In 2008, we hired one centrally-located nurse coordinator for the programme team. …