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STRATEGIC PLAN FOR

HUMAN RESOURCES FOR

HEALTH

2003 to 2017

MINISTRY OF HEALTH KATHMANDU

April 2003

NN EE PP AA LL

P.Hornby\S.Ozcan\R. Ghimire Nepal\shrp2003 2

TABLE OF CONTENTS Page

List of Tables and Diagrams 4 PREFACE 5 FOREWORD 6 I. EXECUTIVE SUMMARY 7 II. INTRODUCTION 12

A. The Purpose of Human Resource Planning 12

B. The Role of a Strategic Plan 12 C. Purpose of This Plan 13 D. For Whom the Plan is Intended 13 E. The Essential Elements of the Plan Contained in this Document 14

III. CURRENT POPULATION AND HEALTH SERVICES 15

A. Population 16 B. Profile of the Health Service and Its Facilities 17 C. Distribution of Staff by Type of Staff 18 D. Staff in Training 19 E. Organisation and Management of Human Resources 20

IV. HUMAN RESOURCE PROBLEMS AND ISSUES 22

A. Problems and Issues Perceived to Exist Now 22 B. Problems and Issues that may occur Over the 24 Next fourteen Years

V. OBJECTIVES OVER THE PLAN PERIOD 26

A. Planning Assumptions 26 B. Changing the Provision of Services 27 C. Proposed Staffing Establishments for Public Sector 29 Health Service Institutions D. Total Staff Expansion 31 E. Number of New Staff to Be Recruited 33 F. Training Needs 35

G. Management of the Workforce 37 VI. POLICY PROPOSALS 39

A. Desirable Changes In Human Resource Activity 39 B. The Strategic Human Resource Development Issue 39


C. Implications of the proposed workforce development 46 for new HR policy

Organisational Roles 47 Staffing Of Facilities 47 Training and Recruitment 48 Employment and Deployment 48 Public/Private Sector Work 49 VII. STRATEGIC IMPLEMENTATION PLAN 51

A. Actions And Activities That Will Be Required 51 VIII. MONITORING AND EVALUATION 54

A. Protocols For Monitoring Implementation Achievements 54

B. Specification Of Important Progress Events 55 C. Process for Annual Evaluation and Replanning of Activities 55

APPENDICES 56

A. Process for Preparing Strategic HR Plan for the Health Sector 58 B. Policy Group and Working Group Participants 59

C. Personnel Categories Used in the Projection Model 60 D. Projected Training Requirements to Meet Staffing Objectives 61 E. Summary of Key Data on Health Sector Changes 62 F. a. Public Sector Income Estimates and Assumptions 63 F. b. Example of Pay Differential Development 64 G. Annual HR Planning (Outline Schedule) 65 H. Data/Information Sources 66


LIST OF TABLES, DIAGRAMS and ATTACHMENT Tables Page 1. Demographic Estimates and Assumptions 2003 to 2017 15 2. Current Health Service Facilities (Public and Private) 17 3. Base Year (2003) Health Workforce Supply 18 4. Total Staff in Training in 2003 20 5. Planning Assumptions 26 6. Projected Funding for the MOH 27 7. Projected Change of Health Service Facilities 28 8. Average Bed Numbers by Type of Facility 29 9. Staff Proposals by Type of Public Sector Hospital 30 10. Staffing Proposals for Health Posts and Sub-Health Posts 31 11. Projected Changes in Staffing Requirement 32 12. Comparison of the Distribution of Staff by Cadre & Category 33 (2003 & 2017) 13. Projected retirement rates to 2017 for selected staff groups 34 14. Projected Requirements for New Recruits 35 15. Projected Training Requirements to Meet Staffing Objectives 36 16. Key Indicators of Change 38 Diagrams 1. Performance and Human Resource Development 40 2. Determinants of Human Resource Development 41 3. Part view of Department of Health organogram 42 4. Organisational Relationships for the HR Division 43 5. How can the HR division/unit/section operational/staffing 45

requirements be met?

Attachment i - xxii A Complementary Report to the Strategic plan for Human Resources for Health 2003-2017: Policies for the Development and Deployment of Medical Specialists in Nepal


PREFACE This strategic human resources in health (HRH) plan has been developed from a foundation of; the 1996 HRH master plan, the 10th health plan and a draft strategic HRH plan produced in 2000 by a working group composed of individuals representing a cross section of relevant interests in the public and private health sectors as well as those responsible for the education and training of health sector staff. This plan document prepared by the Ministry of Health with the support of the GTZ health sector support programme closes a gap in our development initiatives identified as a significant issue in the 10th health plan and provides both direction and a pathway to the development of health human resources through to the year 2017. The plan provides; an analysis of the current situation, institutional staffing objectives, a target for the future workforce, outline proposals for training, essential HR policies and the initial steps for plan implementation. The strategic plan provides a strategic oversight to HRH development and deployment. The plan also provides a framework through which annual HRH planning can take place both nationally and within districts. It adds to the development instruments available to the Ministry of Health for improving health and health care in the country and is to be commended. It is imperative that we seize the opportunity provided through this plan to strengthen and enhance the development and management of the health sector workforce in Nepal.

21 April 2003


FOREWORD

This strategic plan document provides a clear path through to the future and provides a framework for action. Three points raised in the document require our serious attention if this plan is to be turned into a reality which will benefit the people of Nepal. These are that:

to achieve the intentions of the plan the culture of the Ministry must shift from a passive administration orientation to a proactive management driving towards our goals

we will need to invest in and modify our organisational structures, incentives and opportunities to attract and mobilise high quality staff with the capacity to energise and manage the service

we need to strengthen our ability to monitor what is happening and importantly to take action as new problems and issues arise

As this plan document emphasises, this strategic plan is based on what we know today. Circumstances will change and we can only hope for the better given our current situation. However whatever these changes are we must be prepared and able to adjust the plan so that it will continue to be a guiding light for the effective and efficient use of our health workforce to provide better health and healthcare to the people we serve.

Dr Benu Bahadur Karki Chief, Policy, Planning & International Co-operation Division Ministry of Health Kathmandu 21 April 2003


I. EXECUTIVE SUMMARY 1. This document specifies a strategic human resource (HR) plan of action for the

health sector over the next fourteen years (2003-2017). It is based on a draft plan produced in the year 2000 and subsequently reviewed by the Ministry of Health. The plan has been updated to converge with the changing situation in Nepal and improved with the use of more accurate and more comprehensive information than was available during the preparation of the draft strategic plan.

2. The HR strategic plan is intended to accomplish three things. These are:

a. to specify the direction of growth of development of HR: b. to specify outline HR objectives for the medium term which provide a

framework for short-term plan development; and c. to identify short-term actions and, in particular, policy actions which are

needed for the MOH to proceed towards the medium-term future. 3. The document is intended in the first place, therefore, for the Secretary of Health,

Director General and senior officers of the MOH. It provides them with a picture of the implications for health human resources in terms of training, recruitment, deployment and management to meet the medium-term objectives.

4. The document begins with an analysis of the existing and projected future

population characteristics, together with a description of the current profile of the health service and its human resources.

5. Population is expected to grow from its current level of 24 million to just over 33

million over the fourteen-year period of the plan, with birth rates dropping slightly from 34 per 1,000 to 27 per 1,000 but with the population growth rate staying approximately constant at 2.25% per annum. In this period, the urban population is expected to grow from its current level of 12% to 20% of the total population.

6. The number of public sector hospital beds for a population of 24 million is low.

The public sector bed to population ratio is 1 bed to 5,435 population. The situation with regard to bed provision is currently made more difficult by the reported under-staffing and hence under-utilisation of district beds.

7. Occupancy rates for specialty hospitals, regional/central/teaching hospitals, which

constitute 48% of total available beds are extremely high. This level of occupancy in acute tertiary hospitals is undoubtedly creating stress on staff and facilities alike. It is reported that a significant number of the cases presented at these hospitals could be addressed at lower level institutions.

8. The private sector incorporating “for profit” institutions, non-governmental and

mission organisations (NGOs) provide 41% of the total beds. These beds, combined with those of the public sector, provide a theoretical ratio of 1 bed to 2,933 population. They are now and are expected to continue to be an important part of the hospital care provision. However, the distribution of “for profit” beds and tertiary hospital beds is such that access favours the urban population.


9. The number and accessibility of primary care facilities (health centres with beds,

health posts, sub health posts and PHC outreach clinics) providing outpatient services is felt to be sufficient in numbers for the current population. But they need to be strengthened especially in terms of staffing and with increased numbers of sub health posts and outreach clinics to provide adequate access and outreach services to the largely rural population.

10. The total number of staff (34,912) in proportion to the population is low. This is

consistent with the low hospital bed to population ratio discussed earlier. There are, unusually, more specialists than medical officers, reflecting the effects of previous policies.

11. The overall distribution of staff in terms of the mix of skills shows a deficiency in

the middle technical grades. There is currently a high number of unskilled support staff (35% of the total workforce). These staff, together with other support staff, constitutes 70% of the workforce. As the Ministry seeks to raise the skill level of its human resources and its efficiency, it will need to explore opportunities to reduce the volume of unskilled and semi-skilled labour as a percentage of the total workforce.

12. Post-basic training is provided for the principal categories of staff but is more

driven by individual initiatives to gain further training than by Ministry objectives. There is no training in management although this will change this year with the introduction of modular training at the staff college. The role and definition of managers within the service remains ill defined with the focus on administration rather than on management.

13. The Ministry provides a wide coverage in its primary and secondary health care

services. However there is a general problem of under-staffing in all those institutions, particularly in rural areas. This has been a long-standing problem, especially for the more highly trained staff cadres (see 1996 Source Document for the Human Resources for Health Master Plan).

14. The differentials in pay between senior staff and unskilled workers are small. The

ratio of pay between the highest and the lowest grades of staff is approximately 2.8 to 1. Differentials between these grades of staff are more normally between 6 and 10 to 1. Differentials for middle-grade staff to unskilled workers are also low, and provide a little in terms of discrimination between different levels of skills and are in need of reappraisal (see Appendix F).

15. Employment practices have not yet been brought into line with new social and

political philosophies. Current practices maintain the “status quo” of earlier times and will inhibit the development of a modern new style health service. Information on vacancies and on the movement of staff in the service is either not available or not currently assembled or used in a form which will enable planners and decision makers in the Ministry to make consistent decisions in the allocation of new staff. This poses difficulties in developing this strategic plan.


16. It is likely that the Ministry, as it moves to improve the efficiency and quality of the health services, will need to introduce new policies and operational mechanisms to improve its ability to manage systematically the deployment, utilisation, development and careers of its staff. In other words, the MOH will need to take a proactive position on human resource development (HRD).

17. There are no rapid or instantaneous solutions to the problems presented. They

will require a systematic and consistent development programme to actually overcome current problems of human resource supply and utilisation in the health service and the future problems that may emerge. These current and future issues are documented in the text.

18. Therefore, the central issue facing the MOH are not only the current problems to

be addressed, although they are important, but also, more significantly, the need to strengthen the HR planning and management capacity, including HR processes across the health system, that is able to address HR matters on a continuing basis.

19. The working group proposed that there will be no significant expansion in new

public sector hospitals but with physical expansion focused on sub-health posts and the related outreach clinics to strengthen the availability of primary care services. Expansion of sub-health posts is to increase by 32% over the plan period.

20. The high utilisation rates of regional/central/teaching hospitals point to a need to

increase the number of hospital beds of this type at the very least to keep pace with the expected population growth. However, the central concept of improving equity in access to basic primary and secondary care across the country also requires that the staff and available beds in district and zonal hospitals be significantly expanded. It can be anticipated that the development of an adequate network of fully functioning district and zonal hospitals will enable a more effective referral network to be established with a reduction of inappropriate cases presented to tertiary hospitals.

21. It is anticipated that the total health workforce in the public and private sectors

will double from a current level of approximately 35,000 to 72,000 compared with a population growth rate of 40% and with the public sector workforce expanding by 94%. This public sector expansion must be viewed as a major challenge particularly as the staff expansion is mainly focused on professional and technical grades of staff with a consequent increase in training demands for these types of staff and for new teachers and tutors.

22. Information on leaving rates of current and previous health service staff is not

well documented although some information is available through the HURDIS data bank. On the basis of this information, best estimates were made of leaving rates, both from the public health services and the health sector as a whole to enable projections of new recruits. The total of new recruits required to meet expansion requirements and replace leavers was projected to be 42,283

23. The training intake requirements of 47,979 over the period call for substantial

progressive expansion of middle level staff training. With the development of


private medical schools, it is certain that the production of medical officers will exceed the projected sustainable requirements for the public and private sector. The MOH will need suitable recruitment policies in place to ensure it is not over-loaded with medical school graduates.

24. Of particular importance is the management of the flow of the high-level

professionals into the service. For many cadres of staff, this will continue to need to be managed or influenced centrally with mechanisms in place and a comprehensive HR information system to ensure staff of a particular cadre with different levels of skill is adequately distributed around the country.

25. The pressures of finance and improved performance are such that it is not

sufficient simply to expand the workforce. The concepts of human resource development (HRD) and HR management have to come high on the development agenda of the MOH with both increased training and numbers of managers, increased incentives for good management and the provision of adequate numbers of management technical staff.

26. At the moment, the MOH is not sufficiently equipped to undertake the range and scale of development initiatives necessary to achieve significant changes in HRD and health service performance. Significant investment is necessary. It is not

likely that the HR section of the MOH as it currently exists can provide the cornerstone on which HR development can be built.

27. It is currently in the wrong wing of the Ministry located under the executive arm

of the Director General and within the management division. It is also too low down in the organisational structure to be able to discharge the functions normally expected of a HR planning and management unit. The role and responsibilities of a HR unit are of too great a significance for it to be, as it is now, a minor part of another division. Proposals to address the issue are presented in the body of the document (section VI B).

28. HR planning is a subsidiary activity to health service planning in that it is

concerned with the planning of resources to support health service development. However the significance and complexity of this resource and its need for managed development points to the need to maintain the HR unit as a semi-autonomous unit.

29.As the MOH moves towards raising its level of performance and continuing with

the process of decentralisation, it is likely that new or changed HR policies will need to be introduced. Outline policy proposals addressing key areas of managing HR activities are presented in the text. The policies will address:

a. organisational roles; b. staffing of facilities;


c. training and recruitment; d. employment and deployment; e. terms and conditions of employment; f. public and private sector work.

30. The plan document concludes with proposals for initial activities for

implementing the strategic plan and an outline proposal for monitoring, evaluation and replanning. Key indicators of the objectives to be achieved in this period are shown in Appendix E.


II. INTRODUCTION

A. The Purpose of Human Resource Planning The increasing limitations of public health sector resources to meet public demand are leading not only to new forms of association between public and private health systems and the public but also to an increased focus on achieving an efficient and effective, value-for-money provision of health care in the public sector. At the centre of this is the way human resources (HR) are planned, trained and mobilised within the service. For it is the human resources, which are the major determinants of the quality, character and recurrent cost of health care provision. These changes in perspective have increased the need to develop HR planning and management roles, which can lead to an effective and well-motivated workforce. At the core of this is the need to ensure that the health service has the right number of people, in the right place, at the right time, with the right skills, with the right motivation and attitudes, at the right cost, doing the right work. The purpose of strategic human resource planning is to contribute towards the achievement of this ideal. It does so by ensuring that the future needs for and supply of staff are identified and prepared for in time for action, taking into account the needs of the health sector as a whole, likely future staff productivity and projected availability of funding. B. The Role of a Strategic Plan The HR strategic plan is intended to accomplish three things. These are: 1. To specify the direction of growth and development of human resources. 2. To specify outline HR objectives for the medium term which provides a

framework for short-term plan development. 3. To identify short-term actions and, in particular, policy actions which are

needed for the Ministry of Health (MOH) to proceed towards the medium-term future.

All plans of this type are built from current and historical information about HR, projections of future health and health care needs, the types of services to be provided, and the means through which they will be provided. There are clearly numerous uncertainties in all these dimensions, which require regular reassessment of the strategic plan. At the same time, there exists a range of professional judgements about the future from different elements of the health system, which lead to multiple views of the direction in which the MOH should proceed. These views will need to be brought to a


consensus for the purposes of finalising this plan through discussions among planners and decision-makers in the MOH (see Appendix A for process). C. Purpose of This Plan The purpose of this strategic plan, covering a period of fourteen years to the year 2017, is to take a long distance view of how health and health care needs will change and, from that, how the health service and the staff that provide that service will need to change. The period to 2017 is chosen to correspond to the period of the long-term health plan. Included in this long distance perspective is a recognition that the public sector health service will be under increasing financial pressure. As a result, this will require greater efficiency in the operation of the service. At the same time, a more skilled workforce will be needed to meet the aspirations of the public for better and more comprehensive care. The plan also recognises that there will be an increasing need for a viable private health sector working together with the public sector. This document specifies a strategic human resource (HR) plan of action for the health sector over the next fourteen years (2003-2017). It is based on a draft plan produced in the year 2000 and subsequently reviewed by the Ministry of Health. The plan has been updated to converge with the changing situation in Nepal and improved with the use of more accurate and more comprehensive information than was available during the preparation of the draft strategic plan. Nevertheless, it is to be recognised that, even in its final form, this plan like all plans of this kind is created in an environment of political, social and economic uncertainty. It is produced using judgement and the best available information. Undoubtedly new circumstances will arise which will require changes both in the objectives and the actions proposed. For this reason this document also contains proposals for a bi-annual re-evaluation of the plan and for the year-to-year adjustment in activities for the year that follows. D. For Whom the Plan is Intended Human resources are central to any activity in the health service. Nevertheless planning for human resources should not lead the planning of services but rather support it. This HR plan makes proposals for future staff requirements and supply and their allocation on the best available information on the future intentions of the Ministry through its emerging national health plan. The production of the initial draft strategic plan was the outcome of a one-week workshop in Kathmandu (20-25 November 2000). This workshop, involving senior staff across the Ministry and related organisations (see membership list in Appendix B), created a projection of future HR requirements and supply. They used a flexible WHO computer-modelling tool to assist in the production of a picture of the future, which emphasised district institutional and service development. The judgements of this group of senior staff in making these projections were assisted by observations from a steering committee chaired by the then Secretary for Health (see Appendix B).


The same modelling tool was used to produce the modified strategic projection from updated information contained in this document. The essential elements and conclusions arising from the updating was reviewed with a senior policy group which was led by the Health Minister (The Honourable Professor Upendra Devkota) and the Secretary for Health ( Mr Mhendra Nath Aryal) This document is intended in the first place, therefore, for the Secretary for Health, Director General, Director (Planning), Director (Management) and senior officers of the MOH. It provides them with an initial picture of the implications in terms of training, recruitment, deployment and management to meet the HR objectives in the health sector over a fourteen-year period. E. The Essential Elements of The Plan Contained in This Document This planning document contains: 1. An analysis of the existing HR situation. 2. A projection of future requirements for staff in line with the long-term plan. 3. An analysis of the training and training institution requirements. 4. An initial set of policy proposals to support the objectives of the plan. 5. Action proposals for implementing the plan


III. CURRENT POPULATION AND HEALTH SERVICES A. Population Projections in this document of the future population are based on the year 2002 Nepal Population Report, Central Bureau of Statistics information and the National Health Plan document (which was still in preparation) to provide a baseline. Table 1 provides a breakdown of the current and projected future population nationally by age derived from this baseline. Table 1. Demographic Estimates and Assumptions 2003-2017

Assumptions built into this projection over the fourteen-year period include a continued reduction in birth rate and a slow reduction in death rate with a small shift upward in the overall population age. Total population growth over the fourteen-year period is projected as increasing by 37% (approximately 9 million). Population growth is anticipated to be much lower in rural areas (1.6 %) because of migration into urban areas and expected urbanisation of some rural areas. Population growth in urban areas is anticipated to be 6.0% per year as a result of migration and urbanisation resulting in 20% of the population being urban by 2017.

Base Year Target Year Year -----> 2003 2017 Estimated population = 24,228,636 33,083,801 Average annual % population change during period = 2.25 Base Year Target Year Base Year Target Year 2003 2017 2003 2017 Percent distribution by age (Projected) population by age <1 years 2.2 2.0 533,030 660,695 1-4 years 9.9 10.0 2,398,635 3,232,569 5-14 years 27.2 23.0 6,590,189 7,412,672 15-44 years 44.1 46.0 10,684,828 14,809,229 45-64 years 12.4 14.0 3,001,928 4,512,061 65+ years 4.2 5.0 1,017,603 1,611,450 Totals 100.0 100.0 24,226,213 32,238,676 --- Births per 1000 population --- --- Projected births in year ---

34 27 769,048 857,292 --- Urban residents --- --- Rural residents --- Percent 12% 20% 88% 80% Totals 2,907,436 6,616,760 21,321,200 26,467,041 Calculated growth rate = 6.0% 1.6%


The implications of these assumptions are:

1. With population growth and an increasing expectation for health care will come an increased demand for acute services.

2. There will be some shift in demand to the health problems associated with an ageing society.

3. While the existing pattern of disease will continue to dominate, there will be an increased need to address acute illness of the type emerging in wealthier societies (see also Table 5 on planning assumptions).

4. There will be a relatively small shift in birth rate, although demands for improved maternity services are likely to emerge.

5. Urban service facilities will need to be enlarged rather than increased in number to accommodate the shifting population.

The essential statistics of change over the fourteen-year period are proposed as: Population 24 million increasing to 33 million Birth rate 34 per 1000 population dropping to 27 per 1000 Population growth rate approximately constant at 2.25% Urban population currently 12% increasing to 20% of total population B. Profile of the Health Service and its Facilities The MOH provides a range of services, which for the purposes of this planning document are characterised as specialist, regional/central/teaching, hospitals, zonal hospitals and district hospitals, health centres with beds, health posts, sub-health posts and Primary Health Care (PHC) outreach clinics. The distribution of services is shown in Table 2.


Table 2. Current Health Service Facilities (Public and Private)

Type of Facility Number Total Beds % Occupancy* PUBLIC SECTOR Long-stay speciality hospitals 5 275 95 Regional/Central/Teaching hospitals 10 1860 95 Zonal hospitals 10 720 70 District hospitals 67** 1030 60 Health centres with beds 191 573 10 Health posts 701 - - Sub-health posts 3159 - - PHC outreach clinics 13700 - -

TOTAL 17776 4458 72 PRIVATE SECTOR Specialist/NGO/Mission 123 3804 50

Health Sector TOTAL 17899 8262 -- * Estimate **3 district hospitals still under construction The sources for data in Table 2 are HuRDIS, 2003; Association of Private Hospitals in Nepal; Nepal Christian Hospital Association; Birendra Police Hospital; and Birendra Military Hospital. The number of public sector hospital beds for a population of 23 million is low with continuing problems in the geographic distribution of the beds. The bed to population ratio is 1 bed to 5,435 population. At the other extreme, Sri Lanka, for example, has 1 bed to 320 population. The situation with regard to bed provision is currently made more difficult by the reported under-staffing and hence under-utilisation of district beds. Occupancy rates of 95%for specialty hospitals, regional/central/teaching hospitals, which constitute 51% of total available beds are extremely high. This level of occupancy in acute tertiary hospitals is undoubtedly creating stress on staff and facilities alike. It is reported that a significant number of the cases presented at these hospitals could be addressed at lower level institutions if they provided adequate facilities and the appropriate staff. The private sector incorporating both “for profit” institutions, non-governmental organisations (NGOs) and mission hospitals provide 41% of the total beds. They are and will remain a significant element in the provision of hospital care (see 10th health plan). These beds, combined with those of the public sector, provide a theoretical ratio of 1 bed to 2,933 population. However, the distribution of “for profit” beds and tertiary hospital beds is such that access favours the urban population. The number and accessibility of primary care facilities (health centres with beds, health posts, sub health posts and PHC outreach clinics) providing outpatient services is felt to be sufficient in numbers for the current population, but they need to be strengthened especially in terms of staffing to provide adequate access and outreach services to the largely rural population.


The key characteristics of health service facilities are as follows:

Total number of public sector beds 4,458 Ratio of public sector acute hospital beds to population 1 to 5,435

Total acute hospital beds (Public & Private) to population 1 to 2,933 Overall occupancy rates for public sector hospitals and health centres 72%

Ratio of tertiary hospitals to general hospital beds 0.44 Primary health care facilities to population 1 to 5,981*

* (not including outreach clinics) C. Distribution of Staff by Type of Staff Seventy seven percent of all health care workers work in the public sector (see Table 3). A full list of the staff included in each of the staff categories shown in Table 3 is given in Appendix C. Table 3. Base Year (2003) Health Workforce Supply

OCCUPATIONS Supply in % FTE * in FTEs by sector Population

2003 public sector Public Private per worker Medical specialist 1,544 24 363 1,181 14,994

Medical officer 1,186 63 753 433 19,521 Integrated Medical Officer 30 98 29 1 771,714

Dental surgeon/Dentist 236 16 37 199 98,099 Pharmacist 38 37 14 24 609,248

Asst. Pharmacist 69 58 40 29 335,528 Nurse(certificate) 1,585 61 967 618 14,607

ANM 1,820 75 1,358 462 12,721 Graduate nurse 264 73 193 71 87,695

Medical Technologist 42 83 35 7 551,224 Lab technician/Assist. 543 65 353 190 42,636

Radiographer 48 29 14 34 482,321 Asst. radiographer 158 39 61 97 146,528

VHW/MCHW 5,221 98 5,132 89 4,434 AAW/AHW 4,334 98 4,231 103 5,342

HealthAsst./Kaviraj/Hakim 1,558 90 1,397 161 14,860 Allied health occup. 556 64 358 198 41,639

Allied non-med. prof. 594 70 414 180 38,975 Manager 240 99 238 2 95,425

Skilled support staff 2,384 57 1,367 1,017 9,711 Other support staff 12,462 75 9,362 3,100 1,858

Totals 34,912 77% 26,716 8,196 694

*FTE = Full Time Equivalent staff The total numbers of staff (34,912) in proportion to the population is low (1


health staff to 694 people). This is consistent with the low hospital bed to population ratio discussed earlier as it is hospital staffing that generally has the most impact on staffing numbers. There are, unusually, more specialists than medical officers, reflecting the effects of previous policies. Specialists in this presentation also include qualified general practitioners. The overall distribution of staff in terms of the mix of skills shows a significant deficiency in the middle technical grades. There is currently a high number of unskilled support staff (35% of the total workforce). These staff, together with semi-skilled staff, constitutes 55% of the workforce (see appendix D for more detail). As the Ministry seeks to raise the skill level of its human resources and its efficiency, it will need to explore opportunities to reduce the volume of unskilled and semi-skilled labour as a percentage of the total workforce. The category ‘managers’ shown in table 3 does not formally exist among MOH job titles. Nevertheless, managerial posts do exist (see appendix C for definition) and in line with the development of a managerial orientation in the health service will, as elsewhere, require the explicit designation of posts as managerial and, the training and preparation of individuals to fill the posts with the requisite skills. D. Staff in Training The Ministry provides pre-service and in-service training. Doctors, dentists, pharmacists and nurses, including ANMs, are the principal pre-service training programmes provided by the Ministry of Education. Many other categories of allied health professionals are trained through “on the job” training following basic vocational training in high school/school. Table 4 shows current intakes and outputs of basic training.


Table 4. Total Staff in Training in 2003 Study Years Total Total New Total Required Programs Students 2003 Students Medical Specialist 3 5 71 177 Medical Officer 5 9 675 3,238 Integrated Medical Officer 5.5 1 15 83 Dental Surgeon 5 2 120 500 Pharmacist 4 1 28 68 Assistant Pharmacist 1.5 1 15 23 Nurse (certificate/staff) 3 8 730 1,815 ANM 1.5 32 1,050 1,523 Graduate Nurse 4 1 82 286 Medical Technologist 4 1 6 36 Lab Technician/Assistant 1.4 27 1,128 1,974 Radiographer 3 1 4 18 Assistant Radiographer 1.5 1 15 72 VHW/MCHW 0.2 92 450 45 AAW/AHW 1.2 15 4,800 4,914 Health Assistant/Kaviraj/Hakim 3 1 90 225 Allied Health Occupation - - - - Allied non-medical Professionals - - - - Manager - - - - Skilled Support Staff - - - - Support Staff - - - -

Totals xxx 198 9,279 14,995

Post-basic training is provided for the principal categories of staff but currently is more driven by individual initiatives to gain further training than by Ministry objectives. Standards of training are variable and depend more on individual endeavour than on uniform objective-based training standards. There is no training in management although this is about to change with the introduction of modular training at the staff college in May 2003. The role and definition of managers within the service however remains ill defined with the focus on administration rather than on management. E. Organisation and Management of Human Resources The Ministry provides a wide coverage in its primary and secondary health care services. However there is a general problem of under-staffing in all those institutions, particularly in rural areas, with some 40% of sanctioned and filled posts without the incumbent in place. This has been a long-standing problem,


especially for the more highly trained staff cadres (see 1996 Source Document for the Human Resources for Health Master Plan). The differentials in pay between senior staff and unskilled workers are small. The ratio of pay between the highest and the lowest grades of staff is approximately 2.8 to 1. Differentials between these grades of staff are more normally between 6 and 10 to 1. Differentials for middle-grade staff to unskilled workers are also low, and provide a little in terms of discrimination between different levels of skills and are in need of reappraisal (see Appendix G). Employment practices have not yet been brought into line with new social and political philosophies. Current practices maintain the “status quo” of earlier times and will inhibit the development of a modern new style health service. Information on vacancies and on the movement of staff in the service is either not available or is not currently assembled in a form which will enable planners and decision makers in the Ministry to make consistent decisions in the allocation of new staff. This poses difficulties in developing this strategic plan. HR planning does not exist as a formal or regular process, while HR management is addressed in terms of personnel functions, which do not include a strategic view of HR development. The concept of proactive management and manager is not yet established in the Ministry. It is likely that the Ministry, as it moves to improve the efficiency and quality of the health services, will need to introduce new policies and operational mechanisms to improve its ability to manage systematically the deployment, utilisation, development and careers of its staff. In other words, the MOH will need to take a proactive position on human resource development (HRD).


IV. HUMAN RESOURCE PROBLEMS AND ISSUES A. Problems and Issues Perceived to Exist Now The nature of HR problems and issues that affect organisations is the same worldwide. What changes are the magnitude and significance of problems in different organisational settings. For instance, one organisation may have an adequate number of staff but suffer from poor industrial relations and low staff morale while another may have a shortage of staff but high levels of individual commitment. For each of these organisations, the issues posed and the potential solutions are different. The MOH also has its own unique combination of problems for which solutions tailored to these problems need to be devised. 1. General Issues. The broad general issues facing the MOH are:

a. Imbalances in the mix of staff and the skills they represent, particularly in the light of a changing philosophy of health care provision (see table 5). Unless there are some changes in policy, there will be an over supply of some categories of staff (e.g. doctors and unskilled staff) and an under supply of others (e.g. middle-grade technical staff).

b. Imbalances in the geographic distribution of staff with 40% of the sanctioned and filled posts unmanned.

c. Inequalities between different types of health staff in their knowledge and skills and, therefore, in the type and quality of services that can be made available.

d. Problems of job and role definition. e. Inadequate supervision and management control with out-of-date HR

management procedures and employment practices. f. Limited and uncontrolled staff development and career management. g. Severe shortage of trained management staff and management

scientists. h. HRH Information system (HURDIS) of good quality but used primarily

for administration rather than proactive management. i. Low levels of individual and organisational productivity and

performance for some categories of staff with little incentive to improve.

Most of these general issues but not all are addressed in the proposed strategic plan presented later in this document. 2. Operational issues. The general issues in the MOH described above are the

product of a combination of actions taken over a long term and/or failure to take necessary corrective action over an extended period of time. They have occurred in Nepal, as in many other countries, under the combined effects of:

a. Administrative processes not keeping pace with the growth and

increasing complexity of the health service; b. A lack of focus on increasing the general level of knowledge and skills


within the service; c. Concentration on institutional expansion and service volume rather than

service quality; d. A management infrastructure not developing in step with the health

service nor developing with the right orientation to create a health service focused on efficiency and quality.

Linked to these general issues and their causes are other issues relating to the execution of HR processes. These inhibit efficiency in the management and utilisation of human resources. Specifically:

a. There are currently no mechanisms in place to manage the movement of staff into and through the health service and between the public and private sectors.

b. An HR planning unit exists but the capacity for HR planning and policy- making is limited by a shortage of trained HR specialists and support staff.

c. The HR unit should be a planning and policy unit and as such it should be directly linked to the policy-making elements of the Ministry of Health. It is currently inappropriately placed in the Ministry organisational structure and reporting to the director general.

d. Staff attitudes towards their deployment are weakened by inconsistency in the application of personnel regulations and policy.

e. Jobs and roles are currently poorly defined and there are no mechanisms to provide incentives for improved individual performance.

f. The standard of training for many types of staff is not keeping pace with the need for increased and changing skills within the health service as a whole.

g. Staffing establishments are based on institutional staffing norms, which are not related to the actual workload. This is leading to low levels of efficiency and under-utilisation of many of the staff available.

h. Recruitment in the absence of planned objectives is not matching needs and will lead to increased distortion in skill mix.

i. HR performance objectives are not established in most institutions. j. Training of high-level staff is not based on the need for these staff in

the future in terms of objectives for health and health care provision. k. A sound HR information system exists but is not adequately supported

or used to create improved planning and management processes. There are no rapid or instantaneous solutions to these problems or to the more general issues described earlier. They all require time, a political imperative, a committed leadership and resources to achieve a desired change towards a more efficient and effective health service. The plan that follows later in this document suggests that these issues and their solutions should be approached as a set of development initiatives with specified objectives over a precise time frame.


B. Problems and Issues That May Occur Over the Next Fourteen

Years

1. There is likely to be an excess of medical officers and specialists beyond that which can be funded through the MOH budget. This means that over the next fourteen-year period, there will be much more limited opportunity for young doctors to become specialists and an increasing number of specialists and medical officers will need to seek employment in the private sector. As a consequence, it will be necessary for a much closer monitoring of available

posts for specialists and medical officers and much tighter management on the numbers and flow of young doctors into the public sector health service.

2. The need to distribute doctors more evenly in districts will mean that there

will need for greater effort to control and manage the movement of doctors, and indeed other key staff, with the likelihood of new types of contractual agreements to ensure staff move to district areas where they are most needed.

3. The current HR information system is well developed but used only

irregularly to allow appropriate management of staff movement and in danger of collapsing through inadequate Ministry resourcing. The information system is an essential requirement if the required quality of HR management is to be achieved.

4. The number, quality and skills of middle level staff will become a more

central issue as the ministry seeks to upgrade the range and quality of services available to the public. Traditional roles of key staff cadres may need to change introducing greater flexibility in the way services can be provided and requiring modification to existing training programmes

5. Service quality and institutional performance will become a more significant

issue over the fourteen-year period and will require new methods for monitoring activities in institutions across the country.

6. Licensing and relicensing of higher-level staff will become an essential

requirement to maintain standards of practice across both the public and private health sectors

7. Staff salaries, both in absolute terms and in the differential between different

staff groups, will become increasingly significant as an issue as the Ministry attempts to improve efficiency, quality and motivation.

8. The rapidly changing environment for the health service will require much

more clear-cut separation between planning and policymaking and executive functions to enable the Ministry to respond quickly to new emerging issues.


9. The current practice of determining the staffing establishment of health institutions on the basis of the size of the institution will need to change to determining staffing on the basis of the institutional workload if the efficiency of the health service is to be improved.

10. Post-basic training will become increasingly important in developing

knowledge and skills in the health service and will require a more objective-based approach to providing post-basic training.

11. The deconcentration and decentralising of the public health service will put

new demands on the management of the health service and will require district health staff to have management skills that are not at this stage seen to be important.

To address these issues, the Health Service as a whole will need to engage more aggressively with Human Resource Development (HRD). By HRD, in the sense used here, is meant the development and integration of systems, policies and practice in the recruitment, maintenance and development of the workforce to meet the goals of the MOH. In particular this will mean a concerted and sustained effort to develop the functions of HR planning, HR policy making, training, HR data collection, HR management and employee relations. All of these require a commitment of resources and leadership support beyond that which currently exists.


V. OBJECTIVES OVER THE PLAN PERIOD A. Planning Assumptions While the Ministry is still in the process of finalising a strategic direction for its health services, it is likely, from the initial development of the strategic health plan that the direction for HR in health will be determined by: 1. Consolidation of services with no significant growth in numbers of

secondary/tertiary institutions; 2. Expansion and strengthening of primary care facilities; 3. Improvement of the referral system with a strengthening of district and zonal

hospitals with an emphasis on reducing non-tertiary service demands on regional/central/teaching hospitals;

4. Enhancement of the level of skills in the health sector with particular concentration on middle level staff;

5. Promotion of the private health sector; and 6. Development of management skills at centre and district to enable effective

decentralisation of health services. Table 5 shows an outline for the specific assumptions developed by the working groups and used to project future HR needs. Table 5. Planning Assumptions

Dominant morbidity and mortality patterns ---->Aids, TB, Malaria, Mat./Child & chronic diseases will be dominant. Emerging morbidity related to the wealth of the society; cancer/heart diseases /stroke/diabetes Relative emphasis given to public sector vs. private sector --->Limited institutional growth in public sector but strengthening of staffing and management. Private sector will concentrate on specialist acute care Growth rate in public health expenditures --->Remaining essentially in line with growth of GNP. Relative emphasis given to personnel vs. non-personnel expenditures --->Personnel expenditure will remain high but with some shift down in favour of non-personnel expenditure. Relative emphasis given to preventive vs. curative care --->Continued emphasis on preventive care but increased demand for curative care should be planned for. Relative emphasis given to primary care vs. higher-level care --->Strengthening primary care emphasising MCH also emphasising enlarging/strengthening existing district/zonal hospitals Relative emphasis give to ambulatory vs. in-patient care --->Limited expansion of ambulatory units with focus on quality. Major emphasis on local accessibility to sec. inpatients Relative emphasis given to urban population vs. rural population --->Emphasis to be on rural population and non-Kathmandu urban population. Relative emphasis given to high, medium and support level personnel --->Emphasis to be on all categories of medium level staff. Other assumptions that will affect this scenario --->Enhanced quality assurance-- increased cooperation/coordination with other sectors particularly with other elements of health sector.


In translating these assumptions into specific proposals, it is essential that the proposed changes fit inside the expected finances available to the health service. The assumptions on available finances are shown in Table 6 and assume an increased growth in GDP of 6.5% on average over the fourteen-year period of the plan despite current difficulties. However, the proposed staffing and facility expansion proposals have been set to a more conservative overall target growth of 6%, given the uncertainties currently facing Nepal. At the same time, the projection also incorporates a target to keep the percentage of recurrent expenditure on personnel by the year 2017. There remain opportunities to modify these targets as the years of the medium-term plan unfold. Table 6. Projected Funding for the MOH B. Changing the Provision of Services The working group who developed the initial service development concept proposed that there will be no significant expansion in new public sector hospitals but with physical expansion focused on new sub-health posts and the related outreach clinics to strengthen the availability of primary care services. The high utilisation rates of regional/central/teaching hospitals also point to a need to

GROSS DOMESTIC (or REGIONAL) PRODUCT 376,433 Base year Gross Domestic Product (GDP) (000,000 in Rupees) 6.5 Assumed average annual % change (0.0) in GDP BASE YEAR PUBLIC SECTOR EXPENDITURE ESTIMATES (000,000.0 in Rupees) 7,899.6 Total recurrent expenditures (entire public sector) 967.0 Recurrent PUBLIC HEALTH sector expenditures on personnel 301.2 Recurrent PUBLIC HEALTH sector non-personnel expenditures

2000 2017 Index ESTIMATES AND PROJECTIONS 2.1% 2.1% 100 Total recurrent public sector as % of GDP 16.1% 16.1% 100 Recurrent health expenditures as % of public sector 76.2% 70.0% 92 Personnel expenditures as % of public health sector

TOTAL FUNDS (000,000, except Gross Domestic Product per capita) 376,433 909,038 241 Gross domestic product 16,260 28,755 177 Gross domestic product per capita 7,900 19,090 292 Funds for recurrent expenditures, total public sector 1,268 3,073 242 Funds for recurrent expenditures, public health sector 967 2,151 222 Funds for recurrent expenditures, health personnel 5.9%= sustainable average annual % change in personnel expenditures, 2000-->2017


increase the number of hospital beds for this type of hospital at the very least to keep pace with the expected population growth. This was also highlighted in the 10th health plan The central concept of improving equity in access to basic primary and secondary care across the country also requires that the staff and available beds in district and zonal hospitals are significantly expanded. It can be anticipated that the development of an adequate network of fully functioning district and zonal hospitals will enable a more effective referral network to be established with a reduction of inappropriate cases presented to tertiary hospitals. Health centres with beds and low utilisation rates pose difficulties in both staffing and supplying an adequate service. The change in size and role of district hospitals and their geographic relationship to a number of these health centres makes the purpose of some of these health centres with beds redundant and hence the proposed reduction in total numbers of health centres of this type. For similar reasons, there is a proposed reduction in health posts in favour of sub-health posts and a massive expansion in outreach clinics. The projected change in facilities is shown in Table 7. Table 7. Projected Change of Public Sector Health Service Facilities

Number Proposed % Total beds Proposed % Type of Facility in For Change in beds for Change

2003 2017 2003 2017 Speciality L.Stay hospitals 5 5 0% 275 544 98% Regional/Central/Teaching hospitals

10 10 0% 1,860 2,718 46%

Zonal hospitals 10 10 0% 720 1,426 100% District hospitals 67 67 0% 1,030 3,227 213% Health centres with beds 191 191 0% 573 498 -13% Health posts 710 617 -13% - - - Sub-health posts 3,168 4,180 32% - - - PHC outreach clinics 13,700 23,724 73% - - -

TOTAL 17,776 31,958 80% 4,458 8,413 89% The changes shown in the table are not intended to be absolute. Rather they are intended to show a strategic direction, which firstly emphasises growth in numbers of sub-health posts and outreach clinics and, secondly, aims to strengthen all hospital services at different levels of service to cope with population growth and increased public expectations. Of particular importance in this respect is the expansion of selected district hospitals to provide sufficient bed capacity to introduce a range of specialist services at district level.


C. Proposed Staffing Establishments for Public Sector Health Service Institutions The proposed changes in average bed size for different health facilities are shown in Table 8.

Table 8. Average Bed Numbers by Type of Facility

Type of Facility Average number of Beds/facility in Year

2003

Average number of Beds/facility in Year

2017 Speciality L.Stay hospitals 55 120 Regional/central/teaching hospitals

210 300

Zonal hospitals 72 140 District hospitals 15 48 Health centres 3 3 How those additional beds will be distributed in practice for each category of hospital will depend on future judgements about the expansion needs for specific hospitals of a given category (see priorities in 10th plan). For instance, some district hospitals may require 100 beds and some only 20, while the average proposed for this category of hospital is 48 beds. The working group reviewed staffing of the different types of hospital institutions. Changes in the average staffing were made for all these institutions in line with their changing roles. District and zonal hospital middle and high level staff posts were increased to strengthen their ability to provide secondary care while in regional/ central/ teaching hospitals and speciality hospitals overall staffing was substantially increased to enable these hospitals to adequately address more complex case loads. Table 9 shows existing and proposed staffing establishments for hospitals and health centres with beds. The tables show an average number of beds for each type of hospital. The staffing establishments proposed relate to these average bed numbers. These are intended as guidelines only. Actual staffing should be adjusted from hospital to hospital on the actual number of beds and on the actual workload these institutions are experiencing.


Table 9. Staffing Proposals by Type of Public Sector Hospital

(Note: Staff levels shown as fractions indicate individual hospital staff numbers will vary [e.g. 1.5 assistant pharmacists in district hospitals means that some hospitals will have 2 assistant pharmacists and some only 1. Generally there will be 1 assistant pharmacist when there is 1 pharmacist.) Staffing proposals for health posts and sub-health posts emerged from the principle of strengthening these ambulatory units in combination with expanding their number to increase accessibility of primary care services. For health posts, the number of available staff has been increased from 6.3 to 9 per health post and includes the addition of a certificate nurse. For sub-health posts, a similar approach to staffing leads to the proposed inclusion of an ANM post. Total available staff for sub-health posts is increased from 4 to 6 for each sub-health post. The details are shown in Table 10.

HealthCent. with beds Zonal Hospital Sp.L.Stay HospitalDistrict Hospital Reg./Cent. /Tch Hosp

Year 2003 2017 2003 2017 2003 2017 2003 2017 2003 2017Average bed size ---> 3 3 15 48 72 140 210 300 55 120

Medical specialist 0.0 0.0 0.2 4.0 11.7 15.0 19.7 35.0 10.3 20.0Medical officer 1.0 1.0 2.0 3.0 12.4 15.0 32.7 55.0 12.7 20.0

Integrated Med. Officer 0 0 0.2 1.0 0.0 1.0 0.0 0.0 0.0 0.0Dental surgeon 0.0 0.0 0.0 0.0 1.7 3.0 2.7 3.0 0.2 0.4

Pharmacist 0.0 0.0 0.0 0.5 0.2 1.0 0.3 4.0 0.0 2.0Asst. Pharmacist 0.0 0.0 0.0 1.5 0.6 2.0 0.7 7.0 0.7 2.0

Nurse(certif./staff) 1.0 1.0 3.9 10.0 26.8 20.0 63.3 115.0 28.7 40.0ANM 3.0 2.0 2.1 6.0 5.0 40.0 10.3 30.0 4.7 10.0

Graduate nurse 0.0 0.0 0.1 4.0 3.8 10.0 8.0 80.0 0.5 30.0Medical Technologist 0.0 0.0 0.0 0.0 1.2 2.0 1.0 6.0 1.2 2.0Lab technician/Assist. 1.0 1.0 1.0 2.0 1.2 10.0 4.3 20.0 0.0 10.0

Radiographer 0.0 0.0 0.0 1.0 1.2 1.0 1.7 6.0 0.0 2.0Asst. radiographer 0.0 0.0 0.8 1.0 1.2 3.0 3.7 12.0 1.3 4.0

VHW/MCHW 0.0 0.0 0.0 0.0 1.2 0.0 0.0 0.0 0.0 0.0AAW/AHW 2.0 3.0 2.3 3.0 1.2 0.0 15.0 25.0 2.3 3.0

Health Asst./Kaviraj/Hakim 1.0 0.0 1.0 2.0 1.2 6.0 0.0 30.0 1.2 4.0Allied health occup. 0.0 0.0 0.4 0.2 1.2 6.0 6.3 25.0 1.5 8.0

Allied non-med. prof. 0.0 0.0 0.2 1.0 1.2 3.0 6.3 25.0 2.2 6.0Manager 0.0 0.0 0.0 1.0 1.2 4.0 1.0 6.0 0.7 4.0

Skilled support staff 0.0 0.0 1.3 6.0 1.2 5.0 5.0 25.0 3.8 6.0Other support staff 4.0 3.0 12.0 27.0 1.2 60.0 118.7 140.0 29.8 40.0

Total per hospital 13.0 11.0 27.5 74.2 76.6 207.0 300.7 649.0 101.8 213.4 Staff per bed 4.3 4.2 1.8 1.5 1.7 1.5 1.4 2.2 1.8 1.8


Table 10. Staffing Proposals for Health Posts and Sub-Health Posts

D. Total Staff Expansion Likely growth in the private sector, both for NGOs and “for profit” organisations, is difficult to estimate because of the uncertainties regarding growth in individual wealth and willingness to purchase health care. Nevertheless, the Ministry is taking a very proactive approach to the development of the private sector with a view that the private sector will work in partnership with the public sector with particular emphasis for the private sector on the provision of tertiary care. The proposed increase in the private sector is for a growth in beds of approximately 2% per annum, together with some limited growth in specialist ambulatory care services. A consequence of this is that the private sector workforce is expected to increase from its current level of 19% of the total workforce to 29% over the fourteen-year period. It is anticipated that the total health workforce in the public and private sectors will double from a current level of 35,000 to 72,000 compared with a population growth rate of 40% and with the public sector workforce expanding by 71%. This public sector expansion must be viewed as a major challenge particularly as the staff expansion is mainly focused on professional and technical grades of staff with a

Sub Health Posts Health Posts Outreach Clinics

2003 2017 2003 2017 2003 2017Medical specialist 0 0 0 0 0 0

Medical officer 0 0 0 0 0 0Intergrated Med. Officer 0 0 0 0 0 0

Dental surgeon 0 0 0 0 0 0Pharmacist 0 0 0 0 0 0

Asst. Pharmacist 0 0 0 0 0 0Nurse(certif./staff) 0 1 0 0 0 0

ANM 1 2 0 2 0 0Graduate nurse 0 0 0 0 0 0

Medical Technologist 0 0 0 0 0 0Lab technician/Assist. 0 0 0 0 0 0

Radiographer 0 0 0 0 0 0Asst. radiographer 0 0 0 0 0 0

VHW/MCHW 0 0 2 1 0 0AAW/AHW 1.3 2 1 1 0 0

Health Asst./Kaviraj/Hakim 1 1 0 0 0 0Allied health occup. 0 0 0 0 0 0Allied non-med. prof. 0 0 0 0 0 0

Manager 0 0 0 0 0 0Skilled support staff 0 0 0 0 0 0Other support staff 3 3 1 2 0 0

Total per clinic 6.3 9 4 6 0 0


consequent increase in training demands for these types of staff. At the same time, this projection includes proposals to reduce the high proportion of unskilled and semi-skilled staff over the fourteen years as the MOH moves towards attaining higher levels of skills and efficiency in the use of its workforce. Details of the proposed expansion in staffing are shown in Table 11. Table 11. Projected Changes in Staffing Requirement

There are significant shifts in the proportions of staff in different cadres with increased emphasis on the proportion of mid-level professional staff, particularly nurses, to meet the increased demand in primary care services. At the same time, there is a significant drop in the VHW/MCHW posts as these types of staff are replaced by more qualified ANMs. In line with the efforts to raise the overall level of skill in the service as a whole there will be a need to produce more graduate nurses. It is also anticipated that there will be a need for increased efforts to train existing health service managers and to start the process of training and introducing professional managers into the health service in a managed development process. The impact of the proposed staffing changes in the overall skill level in the health sector as a whole is shown in Table 12. The table demonstrates the significant shift

Public Sector Private Sector Total Health SectorOCCUPATIONS Supply in Requirement Supply in Requirement Supply in Requirement New Posts % Change

2003 2017 2003 2017 2003 2017 2003/2017

Medical specialist 371 988 1,173 1,349 1,544 2,337 793 51%Medical officer 747 1445 439 2,014 1,186 3459 2273 192%

Integrated Med.Officer 29 80 1 5 30 85 55 183%Dental surgeon 38 179 198 2,012 236 2191 1955 828%

Pharmacist 14 162 24 345 38 507 469 1234%Asst. Pharmacist 40 251 29 312 69 563 494 716%

Nurse(certif./staff) 967 3416 618 4,016 1,585 7432 5847 369%ANM 1,365 11657 455 3,954 1,820 15611 13791 758%

Graduate nurse 193 1496 71 420 264 1916 1652 626%Medical Technologist 35 119 7 103 42 222 180 429%Lab technician/Assist. 353 871 190 276 543 1147 604 111%

Radiographer 14 181 34 509 48 690 642 1338%Asst. radiographer 62 249 96 265 158 514 356 225%

VHW/MCHW 5,117 4180 104 11 5,221 4191 -1030 -20%AAW/AHW 4,247 6464 87 9 4,334 6473 2139 49%

Health Asst./Kaviraj/Hakim 1,402 1179 156 488 1,558 1667 109 7%Allied health occup. 356 741 200 28 556 769 213 38%

Allied non-med. prof. 416 650 178 55 594 705 111 19%Manager 172 307 74 111 245 418 173 71%

Skilled support staff 1,359 1531 1,025 105 2384 1636 -748 -31%Other support staff 9,346 15586 3,116 4,463 12462 20049 7587 61%

Totals 26,643 51,732 8,275 20,850 34,917 72,582 37,665 XXXX% Change 94% 152% 108%


in proportion to the total for mid-level and highly skilled staff (30% to 55%) with a consequent reduction of the proportion of staff in the support level grade. Table 12. Comparison of the Distribution of Staff by Cadre & Category (2003 &

2017)

E. Number of New Staff to be Recruited The number of staff to be recruited during the fourteen-year period is made up of two parts. These are

1. staff required to meet the expansion of the service and 2. staff required to replace leavers from the existing stock of staff over the

fourteen-year period. A more accurate measure would be to make estimates of the leaving rate on the anticipated average stock of staff over the fourteen-year period. However, the uncertainties surrounding the current pattern of leaving are such that attempting this increased accuracy is not justified. There is limited information on leaving rates from the public service or from the private sector. An estimate based on ages of staff groups (see table 13) providing evidence of retirements in the next fourteen years and experience in countries similar to Nepal has been made as to what the likely leaving rate will be.

Year Year Cadre Category Year Year2003 2017 2003 20174% 3% Medical specialist3% 5% Medical officer0% 0% Integrated Med. Officer 17%1% 2% Dental surgeon High0% 1% Pharmacist Level1% 3% Graduate nurse0% 1% Radiographer 12%2% 1% Allied non-med. prof.1% 1% Manager

0% 1% Asst. Pharmacist5% 10% Nurse(certif./staff) 38%0% 0% Medical Technologist Mid4% 2% Health Asst./Kaviraj/Hakim Level2% 2% Lab technician/Assist.0% 1% Asst. radiographer 18%5% 21% ANM2% 1% Allied health occup.

12% 9% AAW/AHW 70%15% 6% VHW/MCHW Support7% 2% Skilled support staff Level 45%36% 28% Other support staff

% Distribution


Table 13. Projected retirement Rates to 2017 for Selected Staff Groups

Source HuRDIS, January 2003 They have been used in Table 14 to make estimates of the total recruits that will be required over the fourteen-year period to replace leavers in the public and private sectors together. It is proposed as a broad unsupported generality that between 2.5% and 4.0% of different elements of the workforce will leave the public sector workforce each year with the rates adjusted to reflect expected retirements. Within this total number of leavers, it is further proposed that 2% per year will leave the public sector to work in the private health sector. The private sector will itself also face staffing losses over fourteen-year period. These, compounded with the public sector workforce leaving and not joining the private sector, generate the total losses from the health sector workforce. The results of this, combined with additional staff requirements, specify the number of new recruits required over the fourteen-year period. They total 42,283 (see Table 14).

Total Staff % of all Projected Category over 45 years Staff in Retirement

in 2003 Category Rate to 2017

Doctors 313 36 2.6%Nurses 598 17 1.2%

Paramedics 1178 21 1.5%Public Health Staff 106 54 3.9%

Support Staff 1463 27 1.9%


Table 14. Projected Requirements for New Recruits

The numbers presented in Table 14 suggest a good deal of precision in forecasting the future requirements for staff. However, there are numerous uncertainties in making these projections, including future leaving rates for staff. As a consequence, these projections should be seen as providing a reasonable estimate of future requirements for new recruits sufficient to provide a picture of the scale and pattern of training intakes over the short term. F. Training Needs The requirements for training emerging from the projections are shown in abbreviated form in Table 15 and in detail with projected annual intakes in Appendix D. The projected losses during training (drop outs, sickness and failure) are estimates of the working group as data on this aspect of training was not available at the time.

MOH Estimated Transfer to Estimated Priv.Sector Estimated Estimated Additional Total

Staff Type Staff Leavers in Priv.Sector Loss to Staff Leavers total loss staff Req. Recruits

in 2003 14 years @2%/year H.Sector in 2000 @2%/year to H.Sector Required

(a) (b) (c) (d)=(b-c) (e) (f) (g)=(d+f) (h) (i)=(g+h) Medical Specialist 371 208 104 104 1,173 328 432 793 1225 Medical Officer 747 261 209 52 439 123 175 2273 2448

Integrated Med.Officer 29 10 8 2 1 0 2 55 57 Dental Surgeon 38 13 11 3 198 55 58 1955 2013

Pharmacist 14 5 4 1 24 7 8 469 477 Assistant Pharmacist 40 14 11 3 29 8 11 494 505

Nurse (certificate/staff) 967 338 271 68 618 173 241 5847 6088 ANM 1,365 478 382 96 455 127 223 13791 14014

Graduate Nurse 193 68 54 14 71 20 33 1652 1685 Medical Technologist 35 12 10 2 7 2 4 180 184

Lab Technician/Assistant 353 124 99 25 190 53 78 604 682 Radiographer 14 5 4 1 34 10 11 642 653

Assistant Radiographer 62 22 17 4 96 27 31 356 387 VHW/MCHW 5,117 2149 1433 716 104 29 746 -1030 -285 AAW/AHW 4,247 1486 1189 297 87 24 322 2139 2461

Health Assistant/Kaviraj/Hakim 1,402 491 393 98 156 44 142 109 251

Allied Health Occupation 356 125 100 25 200 56 81 213 294 Allied non-medical

Professionals 416 146 116 29 178 50 79 111 190

Manager 172 60 48 12 74 21 33 173 206 Skilled Support Staff 1,359 476 381 95 1,025 287 382 -748 -366

Support Staff 9,346 3271 2617 654 3,116 872 1527 7587 9114Total 26,643 9,761 7,460 2,301 8,275 2,317 4,619 37,665 42,283

Note: minus sign in "recruits required" column means excess staff


Table 15. Projected Training Requirements to Meet Staffing Objectives (Abbreviated Table - for full table see Appendix D)

Notes: 1. The intake for medical specialists comes from the medical officer category. A correction has been made in the medical officer training intake to allow for additional trainees to replace existing medical officers who move to the specialist grade. 2. some of the intake, but not all, for ANM training will come from existing VHW/AHWs . 3. Training for VHW/AHWs is to be discontinued. 4. Certain categories of staff are not included in the training because the training is either not controlled by the MOH or no training is required. 5. The total intake includes includes trainees who will not graduate by 2017. The total intake requirements of 47,979 call for substantial progressive expansion of middle level staff training. With the development of private medical schools, it is certain that the current production of medical officers will exceed the projected sustainable requirements for the public and private sector. The MOH will need suitable recruitment policies in place to ensure it is not over-loaded with medical school graduates. The size of training expansion required for certain categories of staff (e.g. dentists, radiographers and graduate nurses) provides an opportunity to consider the development of multiple training sites for these and other categories of staff.

Total Year 2003 Total Expected Intake Total intake Total intakeOccupation Recruits intake already Losses in required in to meet 2003

Required already in in Training period 2003/2017 to2003-2017 Training Training 2003-2017 2004-2017 requirements 20175

Medical Specialist 1,225 71 177 61 1,110 1,181 1,541 Medical Officer 1 2,448 675 3,238 147 467 1,142 1,342

Integrated Medical officer 57 15 83 6 0 0 15 Dental Surgeon 2,013 120 500 201 1,714 1,834 3,084

Pharmacist 477 28 68 48 456 484 724 Assistant Pharmacist 505 15 23 101 583 598 748

Nurse (certificate/staff) 6,088 730 1,815 1,218 5,490 6,220 7,720 ANM 2 14,014 1,050 1,523 2,803 15,294 16,344 19,944

Graduate Nurse 1,685 82 286 169 1,568 1,650 2,530 Medical Technologist 184 6 36 37 185 191 271

Lab Technician/Assistant 682 1,128 1,974 170 0 1,128 1,128 Radiographer 653 4 18 163 798 802 1,162

Assistant Radiographer 387 15 72 97 412 427 527 VHW/MCHW 3 -285 450 45 0 0 0 450

AAW/AHW 2,461 4,800 4,914 615 0 4,800 4,800 Health Assistant/Kaviraj/Hakim 251 90 225 63 89 179 179

Allied Health Occup'n 4 294 - - - - - - Allied non-medical Professional 190 - - - - - -

Manager 206 - - - - - - Skilled Support Staff -366 - - - - - - Other Support Staff 9,114 - - - - - -

Total 42,283 9,279 14,997 5,898 28,165 36,979 47,949

Note: minus sign in "recruits required" column means excess staff


The total number of teachers/tutors will reduce from current FTE levels estimated at 2,000 to approximately 1600 but with a focus on middle and higher level staff requirements. There will be a significant shift in the qualifications and expertise required and hence for the training of new teachers and tutors. G. Management of the Workforce The word ‘management’ is used in this document to refer to the general control of training, recruitment, distribution and mobilisation of the workforce. Part of the process for moving the management of human resources from an administrative process to pro-active management has already started with initiatives associated with decentralisation. This medium-term HR plan is part of this development. New issues will emerge during the medium term on how management of the workforce will be achieved in a decentralised system to ensure equity in the provision of services, improved quality and range of services across the country and demonstrable improvements in efficiency. Of particular importance is the management of the flow of the high-level professionals into the service. For many cadres of staff, this will continue to need to be managed or influenced centrally with mechanisms in place and a comprehensive HR information system to ensure staffs of a particular cadre, with different levels of skill, are adequately distributed around the country. This will require new policies, which are discussed in Section VI of this plan and must include new approaches to the career development for many of the higher-level professional cadres. The expansion and proposed role of the private sector will also require new concepts around private and public sector employment. These also are addressed in Section VI, although in a preliminary way, because there is a requirement for further analysis of the current situation, as well as more exhaustive dialogue between the relevant decision makers. With the continuing pressures on finance and for improved performance, it is no longer sufficient to establish staffing requirements on the basis of staffing norms that are unrelated to workload and operational efficiency. As a consequence, the concepts of human resource development (HRD) and HR management have to come high on the development agenda of the MOH with both increased training and numbers of managers, increased incentives for good management and the provision of adequate numbers of management technical staff. These changing requirements will need a more intense monitoring of human resources than is currently the situation. This will require distribution of staff with skills and roles to promote HR performance across the country. The use of HR performance indicators is recommended as a necessary condition for enhancing and equalising performance across the country; GTZ, in conjunction with WHO and the MOH, has pioneered a pilot study on its application. The overall outcomes of the proposals contained in the previous sections of this report are shown in detail in Appendix E. Some key changes in terms of service


provision are shown in Table 16. Table16. Key Indicators of Change

YEAR YEAR 2003 2017 Projection years = 14

24,228,636 33,083,801 Total population

694 456 Population per health worker 14 22 Health workers per 10,000 population

34,912 72,602 Total health personnel included in scenario 76% 71% % of all health workers in public sector ------ 5.4% Average annual % change in health personnel 0.4 0.4 Total public and private beds per 1000 population

8,509 13,969 Total number of hospital beds 3,804 5,159 Number of private sector beds

18 26 Hospital discharges per 1000 population


VI. POLICY PROPOSALS

A. Desirable Changes in Human Resource Activity The MOH will continue to need to operate under tight financial constraints. Staff pay and benefits presently consume 76% of the recurrent health service budget. The commitment to expanding the workforce, combined with a need to provide health service staff with improved pay and benefits, raise the overall skill level of the workforce and reduce the overall percentage of recurrent costs attributed to its human resources will require that the MOH seeks greater efficiency in the use of its human resources. It must do so if it is to ensure that the health of the nation and the health service itself continues to improve. The implications of this in the medium term are to suggest that the MOH should focus on:

1. establishing a process for human resource development which will encompass: strengthening HR planning; monitoring and managing workforce and institutional performance; increasing the purpose and focus of staff training; and revamping personnel policies and practices to encourage individual and organisational achievement (see Appendix F);

2. substantially strengthening primary and secondary care services, particularly at district and zonal levels, in number, capability and skill mix;

3. ensuring the managed deployment of staff and their career development; 4. introducing more flexibility into institutional staffing to accommodate levels of

workload rather than relying simply on the staffing norms associated with certain types of institution;

5. increasing the basic training capacity for middle level professional staff and improving the match between future needs for all staff and the level of training provision;

6. modifying the pay and compensation packages to improve productivity and commitment;

7. improving the capacity of the MOH to manage the movement of staff within the public sector and across the public/private sector interface;

8. strengthening the HR planning and management capability throughout the health system to improve deployment and utilisation of health staff; and

9. developing an HR information system that can support the needs of managers at district, provincial and central levels.

B. The Strategic Human Resource Development Issue What is at issue here for the MOH is not simply (as in the past) the expansion of facilities and increases in the workforce. This solution by itself is not viable in this country or indeed in most other countries. But rather the need for concerted action to mobilise new resources from within and outside the MOH; coordinate the use of existing resources; and improve the effectiveness and efficiency of the application of these resources. To do this will require new orientations, skills and organisational roles within the MOH. These changes are needed to create a capability to address the array of new and


more complex demands inherent in efforts to improve health sector performance in a decentralised health system. The dimensions of these new demands for HR management are summarised in the diagram that follows. Management performance is now seen along side traditional clinical performance as a legitimate part of MOH goals and objectives. Its inclusion creates a need to incorporate new concepts and practices into the regular activities of the Ministry.

Diagram 1. Performance and Human Resource Development

Focus for Improved Health Sector Performance

Efficiency

Equity

Appropriateness

Effectiveness

Accessibility Acceptability

Implications for Changes in Human Resource Development

Quality

of staff

Mix of staff

cadres

Number of staff

Staff distribution

Staff productivity

Education & training

Human resources

management The need to engage with these organisational variables (viz: quality of staff etc) is not new. They have not received however much attention in the past with concentration instead largely on increasing numbers of staff and expanding the volume of training. The emerging public sector financial constraints and demands for higher levels of efficiency and effectiveness require a change in priorities. Human Resource Development In HR terms, the MOH will need to engage substantively with the issues of HR development (HRD) across the entire health sector. HRD, in the sense used here, is the development and integration of systems, policies and practice in the recruitment, maintenance and development of the workforce to meet the goals of the MOH (see Diagram 2). Relatively rapid changes in social and political attitudes in this country and elsewhere are leading towards increased demands for improved health service planning and management. At the centre of this are human resources. Consequently it becomes essential that the MOH develops a capacity to address the organisational processes


that impact on improved performance within the health system. Specifically the MOH will need to strengthen mechanisms that improve:

Diagram 2. Determinants of Human Resource Development HRD Resources: Budget HRD Staff and Staff skills HRD Planning: Mission and Goal Setting HRD Planning & Policy Development Personnel Policy and Practice: Job Classification System Compensation and Benefits System Career System Recruitment, Hiring, Transfer and Promotion Personnel Policies Discipline, Termination, Grievance Procedures Other Incentive Systems Union Relationships Labour Law Compliance

HRD Data: Employee Data Computerisation of Data Personnel Files Health Sector Workforce Information Performance Management Job Descriptions Supervision Performance Planning and Evaluation Accreditation Training: Staff Training Management/Leadership Development Links to External Pre-Service Training

At the moment, the MOH is not sufficiently equipped to undertake the range and scale of development initiatives necessary to achieve significant changes in HRD and health service performance. Significant investment is necessary. It is not likely that the HR section (HRs) of the MOH as it currently exists can provide the cornerstone on which HR development can be built. It is currently in the wrong wing of the Ministry located under the executive arm of the Director General and within the management division (see diagram 3). It is also too low down in the organisational structure to be able to discharge the functions normally expected of a HR planning and management unit. It is nevertheless this unit that other units of the ministry relevant to HRD should be linked. The role and responsibilities of a HR unit are of too great a significance for it to be, as it is now, a minor part of another division. Diagram 3. Part View of Department of Health Services Organogram


The Role of a HR planning Division A planning division is normally expected to discharge the following functions:

1. To manage the process of producing long term, medium and annual

HR plans.

2. To provide technical support in the production of HR plans.

3. To coordinate HR plans and planning activities with the work of

health and health service planners including the planning of training.

4. To undertake or commission research into the deployment,

management, training and performance of health service staff.

5. To develop HR policy options to facilitate the achievement of health,

health service and human resource goals and objectives.

6. To provide advice, information to top management decision makers

on HR matters.

7. To determine the type and volume of training that will be required.

8. To monitor HR and HR management performance

9. To develop standards for HR planning and management.

10. To maintain a coordinating and communicating network with

appropriate departments of relevant other ministries and agencies.

11. To provide a clearing house for HR information

These functions all point to the HRs acting, in the broadest sense of the word, as a policy unit and not as an executive/decision-making unit. However to discharge its role, the HRs needs to have a number of connections with other elements of the health

Management Division

Budget, Program & Human Resource Section

Monitoring, Evaluation & Quality Control

Management Information System

Building Construction, Maintenance Section

Administration Section

Financial Administration Section

Department of Health Services

Director General

Management Division

Budget, Program & Human Resource Section

Monitoring, Evaluation & Quality Control

Management Information System

Building Construction, Maintenance Section

Administration Section

Financial Administration Section

Department of Health Services

Director General


service organisation and outside it which have executive roles. These are shown in Diagram 3.

Diagram 4. Principal Organisational Relationships for the HRs

The nature of the relationship between HRs and the other units should be of four types: Reporting Ministry top management Health service planning unit

Controlling Training Unit Cooperating Health service planning unit Management Information unit Coordinating Personnel District management HR planning is a subsidiary activity to health service planning in that it is concerned with the planning of resources to support health service development. However the significance and complexity of this resource and its need for

HRDDivision

PublicServices

Commission

Ministry Of

Finance

MOHTop

ManagementDHS/Mgmt.Division

HuRDIS/HMIS

Policy, Planning& International

Coop’n.Division

Regional andDistrict

Health Offices

HealthTrainingCentre Ministry

OfEducation

ExternalDevelopment

Partners

PrivateSector

Organisations

Academic &Training

Institutions

Personnel

N P C MOGA

HRDDivision

PublicServices

Commission

PublicServices

Commission

Ministry Of

Finance

Ministry Of

Finance

MOHTop

ManagementDHS/Mgmt.Division

HuRDIS/HMIS

Policy, Planning& International

Coop’n.Division

Regional andDistrict

Health Offices

HealthTrainingCentre Ministry

OfEducation

Ministry Of

Education

ExternalDevelopment

Partners

ExternalDevelopment

Partners

PrivateSector

Organisations

PrivateSector

Organisations

Academic &Training

Institutions

Academic &Training

Institutions

Personnel

N P C MOGA


managed development points to the need to maintain the HRs unit as a semi-autonomous unit. As part of its work, the HRs will need to determine and plan for future training requirements. In this role, it may well need either to have a coordinating or controlling role with a unit responsible for organising or arranging training. The planning activity of the HRs will inevitably require it to explore a range of new or modified HR policies to achieve the ministry’s intentions with regard to the recruitment, deployment, training, utilisation and mobilisation of staff. This will require the HRs to work in cooperation with any superior policy unit, which may be attached to the minister’s, or director general’s office. The type of policy issues the HRs will be concerned with will differ from that of a policy unit and as such it is not in a line of command relationship with that unit. The HRs will need to gather information for its activities from a variety of sources including the commissioning of specific research. In addition it will gather information from Personnel and from any Management Information unit that may exist. HRs needs to be able to influence the nature of the information collected and the way it is processed for HRs. Currently this work is largely undertaken by GTZ but with reporting on a voluntary rather than mandatory basis. The HRs will have a general responsibility for providing and disseminating HR information. It is the office where all general information on HR should be located other than individual staff details, which should be in the personnel data bank. It is for this reason that HRs will need to have processing software to enable it to translate raw data from the personnel and management information units into aggregated HR information The HRs will almost certainly have some responsibilities for ensuring that plans and policies, which it has caused to be generated, are implemented. To do this will require it to have some formal links with personnel and with that part of the decentralised management structure of operational units of the health service concerned with HR management and development. While this generally does not imply a line of command relationship it does imply that the HRs is provided with sufficient authority that its advice and guidance is acted on by these other units. Finally the HRs will need its own set of operational links with other ministries and agencies that will impact on HR planning and management in the health sector. Generally the ministries that are most important in this respect are the Public Services Commission, National Planning Commission, the Ministry of Finance and the Ministry of Education. The HRs should seek to represent the Ministry of Health on HR matters with these and other relevant institutions including professional associations. The HRs needs staff with specialised skills, which can enable it to take a leadership role in matters relating to all the dimensions of HR development in the health sector. At the moment it lacks these “technical skills” in quality and quantity. In the short term it must either rely on imported consultant support or


limit the activities of the unit to that which can be undertaken with the existing array of skills. It is important that new young staff are developed in the necessary planning and policy-making skills any HR department needs. The unit if it is to take a full part in guiding district management in the development of an effective district HR function will need these skills. The HRs is currently undermanned. The HRs should seek to create posts at the earliest opportunity to employ degree level HR “technical staff ”. It is likely the unit will require at minimum, in addition to its director, two HR planners, one statistician and one behavioural scientist together with appropriate secretarial and computer support staff and graduate level research assistants. The technical staff should be fully qualified in these disciplines. The HRs will require an array of development resources to make the steps forward it needs to make for the ministry to use its human resources more efficiently. HR is the most significant and costly resource the ministry possesses. A development programme should focus on three critical areas of HR planning and management capacity building. These are: HR data and information, HR planning capacity and HR management. Diagram 5. How can the HR division/unit/section operational/staffing requirements be met?

Problems: The MOH is trying to reduce staff not increaseThe existing HR section is in the wrong placeThe MOH doesn’t have the right staffThe MOH is not convinced of the benefits of such a unitThere is too much movement in the MOH to create a stable new unit

A Route forward could be:1. To move the HR unit to the ministry and the personnel division to the

department 2. The creation of a special team inside the MOH for 5 years3. The team to be drawn from the MOH, IOM, Staff College4. Financial support from MOH and development partners5. MOH staff contribution will be limited and may draw an appropriate6. staff member from the NHTC7. At least two senior staff to be full time & other senior staff at least8. three quarters full time on deputation to the team9. Organisational location to be as a separated unit of the NHTC if the project10. could not be given a place within the organisational structure11. Team will not report to the NHTC but to the Secretary or Health12. In years 3, 4, 5 one university non-medical graduate from among 13. the research assistants sent in each year for post graduate training in H.R.D.14. Specific time to time support from international experts including

development agenda

Problems: The MOH is trying to reduce staff not increaseThe existing HR section is in the wrong placeThe MOH doesn’t have the right staffThe MOH is not convinced of the benefits of such a unitThere is too much movement in the MOH to create a stable new unit

A Route forward could be:1. To move the HR unit to the ministry and the personnel division to the

department 2. The creation of a special team inside the MOH for 5 years3. The team to be drawn from the MOH, IOM, Staff College4. Financial support from MOH and development partners5. MOH staff contribution will be limited and may draw an appropriate6. staff member from the NHTC7. At least two senior staff to be full time & other senior staff at least8. three quarters full time on deputation to the team9. Organisational location to be as a separated unit of the NHTC if the project10. could not be given a place within the organisational structure11. Team will not report to the NHTC but to the Secretary or Health12. In years 3, 4, 5 one university non-medical graduate from among 13. the research assistants sent in each year for post graduate training in H.R.D.14. Specific time to time support from international experts including

development agenda


C. Implications of The Proposed Workforce Development for New HR Policy The distribution of health service staff is less than optimum for the population served. This is both in terms of sanctioned posts and actual staff in post. The proposed changes in district and zonal facilities and services in this strategic plan will necessarily help to address the issue of sanctioned posts. However, to achieve actual improved staff deployment will require more fundamental changes to existing management practice. Without these changes, the objectives of this strategic HR plan will not be achieved (see also Recommendations of Human Resources for Health Master Plan - June 1996). As a consequence, it is necessary to consider introducing policies for staffing health facilities and the training and deployment of staff which will allow the MOH to prioritise the filling of vacancies against perceived need and, at the same time, to re-specify posts from one cadre of staff to another to achieve a better skill balance within different institutions. It will also require the introduction of some form of workload-based staffing assessment method. Work Indicators of Staffing Needs (WISN) may be a useful method as it allows a comparison of needs between similar types of institutions. This will need to be supported by the introduction of mechanisms for monitoring of individual institutional performance. Given the recognition in the plan that a private sector service of significant proportions will emerge over the next ten years, new policies will also be necessary to improve the management of staff moving within the public sector and between the public and private sectors and in the regulation of private sector activity. The policies that will need to go into place to achieve the intentions of the MOH encompass all dimensions of HR activity, including:

1. organisational structures and roles; 2. staffing of facilities; 3. training and recruitment; 4. employment and deployment; 5. terms and conditions of service; 6. public and private sector work.

The outline policy proposals that follow address key issues in managing HR activity.


1. Organisational Roles a. Responsibility for "coordinating and supporting" HR planning activities at all

levels of the health system will be with a national level HR planning unit. b. National HR planning will include the totality of health workforce needs including

those of public sector organisations, non-governmental organisations (NGOs) working within the public sector and private sectors and the for-profit private sector.

c. Each region will have an HR planning function appropriate to its role and

independent of the personnel function but contained within a single unit responsible for HR performance (see also HR management).

d. Planning for future staff requirements will be determined on the basis of health

needs, workloads and available finance. (NOTE: links to WISN development). e. Districts, regions and the national level will share responsibility for monitoring HR

performance and for taking action to improve performance. f. Prime responsibility for initiating and coordinating continuing education and post-

basic training programmes in the public sector will rest with the national MOH. g. Post-basic training will be determined either by organisational objectives or the

requirements for continuing professional accreditation. 2. Staffing of Facilities a. Staffing of all institutions will be on the basis of staffing norms which may change

over time and for which an annual review is targeted b. Staffing norms will be increasingly workload based and specific to individual

units. c. Minimum and maximum levels of staffing will be determined on the basis of

workload, performance standards and availability of related staff. d. District managers will be responsible for determining local variations in staff mix

within clinical safety standards established by health professional committees at national level.

e. Funding for staffing of individual units will similarly be based on work load based

staffing norms. f. By the year 2006, all professional health staff in the public and private sectors

must undertake accredited training bi-annually in order to retain their professional status. The management of the process to be through the professional societies with appropriate support from educational and training institutions.

g. All staff will be subject to an annual appraisal, the purpose of which is to identify


personal development needs and training requirements to meet the objectives of the local organisation.

h. A university-level management cadre is to be progressively created. 3. Training and Recruitment a. Employment in the health service is not guaranteed for graduates following clinical

training/education. b. Post-graduate management training centres will be established to meet the

management training needs of the health service and provide training through direct and distance learning methods.

c. Training of technical and administrative/management cadres will be given

increased emphasis in line with identified needs for more skilled human resource management

d. Levels of unskilled worker will be progressively reduced through natural wastage

and “below replacement” recruitment. e. Identification of training needs will be provided by districts and provinces on an

annual basis. f. The accreditation and validation of training programmes and the maintenance of

training standards will be the responsibility of the MOH through a health council of professional boards.

g. Training will be increasingly focused around the identification of needs to raise

staff competency and skills in line with the objectives of local organisations. h. Objective-based staff appraisal will be the principal method of determining the

personal development needs of individual staff. i. All managers to receive mandatory basic training on a regular basis in management

skills appropriate to the management level they hold. 4. Employment and Deployment a. All staff will be provided with the opportunity for at least two levels of promotion

over a full service career. b. By 2005, all jobs will be progressively described in terms of requirements of

competency, skills and capability. c. Deputation of staff will be allowed only under exceptional circumstances and is

intended to meet priority shortfalls in approved institutional staffing.


d. Regular staff appraisals will be introduced which assess individuals in the same terms as are applied to describing jobs and which will be tied, over time, to improving individual contributions to corporate goals and objectives.

e. All posts above those at entry will be filled by open competition. Local

organisations will determine the minimum level of competency and skills to qualify for the post.

f. The grades of staff will be determined by the jobs they hold. g. Pay differentials will be incrementally expanded in line with comparable

differentials in the private sector (see Appendix F for an example on one option). 5. Public/Private Sector Work Certain cadres of staff have advantageous opportunities to work in the private sector. Because of this, the MOH may wish to control or at least influence both the movement of staff into private sector and the degree of cooperation that exists between the public and private sector activity. The areas in which it may be desirable to develop policies are as follows: Part-time working for selected staff categories Controlled access to the use of public sector facilities Bonding and licensing Standard setting for service quality Public/private institution partnerships Some possible policies relating to the action areas identified above are as follows: a. All professional grade staff and, in particular, degree level personnel will be

required to provide a period in a public health service, irrespective of whether their training was government supported or not. Those who receive fellowships or loans from public funds will be bonded for a reasonable period of time.

b. Bonded staff may not be licensed to practice until the time required by the bond

agreement is fully discharged. c. Access to publicly funded postgraduate training will be open only to full-time staff

working in the public service. d. From 2004, all health professionals must be licensed to practice with a biannual

renewal of licence mandatory. e. Licensing standards will be determined from time to time by the MOH in

conjunction with appropriate professional bodies. f. Only specialists may have joint public/private sector appointments. g. Similar training and examination standards to be applied for pubic and private

training institutions.


h. Private training institutions may be sub-contracted to assist in training middle-level

staff. i. Where appropriate, incentives may be introduced to private institutions willing to

absorb medical graduates.


VII. STRATEGIC IMPLEMENTATION PLAN A. Actions and Activities That Will be Required 1. In the medium term to the year 2017, the focus for the total health sector

workforce including both the public and private sectors should be on achieving a significant change in total staffing (approximately 5.4% increase per year). At the same time, there will need to be a substantial redistribution in the types of staff employed in the public sector moving towards the target of an increased proportion of total staff and higher level skills in the middle grades of the service.

2. The period to 2017 will have multiple objectives. It will seek to improve

efficiency in the use of facilities and staff and, at the same time, increase accessibility for outpatient services at local level, as well as seeking to strengthen the referral system, particularly with reference to the use of district hospitals and primary care facilities.

3. The intention of the MOH to involve the private sector in partnership arrangements

in the provision of tertiary care has staffing, organisation and funding implications which may need to be explored through pilot schemes starting in 2004 to test the mechanisms for a linked referral system.

4. The proposed growth of approximately 4,000 public sector hospital beds is of

sufficient magnitude that a programme of capital development priorities will need to be established during 2003 and 2004, with the first of these schemes focusing on district hospitals coming on stream in 2004 with appropriate levels of new posts created in step to support these schemes.

5. Staffing for all institutions should be increasingly determined on a workload basis

(WISN) and then, by the year 2006, through a combination of workload and performance standards. Priority for staff deployment should follow staffing needs identified through the workload methods and be put in place during 2004.

6. The proposed staffing for health services has been adjusted to provide a differential

skill mix for different types of institution. It is proposed that following the initial workload-based staff development process, a function analysis of hospital and primary care centre activities should be undertaken over a two-year period, starting in 2005, to provide a more rigorous base for establishing future staffing establishments.

7. There needs to be significant changes in the capacity for training staff, particularly

mid-level staff, and these need to be prioritised and agreed during 2003. Where there are proposals for capacity reduction, such as in the training of medical officers, this may need to be accompanied by new policies on post-graduate training and employment.

8. Current pressures to reduce or change staffing (particularly unskilled workers)

should be achieved through natural wastage or disestablishment of posts as they


become vacant. The focus for reducing staffing costs should not be on freezing posts but rather on targeting a reduction a staffing costs and allowing redistribution of posts inside a cost envelope.

9. The emerging pressures to improve efficiency and effectiveness (performance) will

require increased attention on supervision and performance management. It is proposed, following the limited trial of HR performance monitoring in 1999, that this be extended more widely as a pilot in 2004 with a view to its expansion nationwide in 2005 and 2006.

10.Performance management will require that a fully fledged management

information system is put into place and fully functioning by 2005, both at district and central management levels.

11. Decentralisation and the dispersal of responsibility to provinces and districts will

require enhancement in the training of existing managerial staff. It will also require the introduction over time of professional managers to train within the health service. At this stage, it is not possible to attract significant numbers of non-medical university graduates into the service. To do so will require the creation of a management cadre which, over the thirty years, can be expected to produce managers suitable for the highest levels of the service. The process for developing these managers will take a substantial period of time and should start with the creation of this cadre and suitable posts for junior managers in 2004.

12.Human resource development will require a strong focal unit capable of initiating

and maintaining HRD activities. The core HR planning and policy unit should be expanded during 2003, with key staff sent for training at the earliest possible date (see diagram 5 section VI). This unit should be organisationally positioned to have direct access to higher level decision makers in the MOH and other ministries and be the conduit through which the development of HR planning and management capabilities in the regions and districts can take place.

13.With regard to private sector activity, the MOH will need to both encourage

appropriate private sector development and seek to manage the movement of public health sector staff into the private sector. The MOH may wish to encourage a mixed strategy of self-standing private institutions and private wings attached to public institutions, enabling the private sector to share in and contribute to expensive public sector facilities and equipment.

14.It will be essential, particularly for the most senior health professional grades, to

have the possibility of access to private work if they are to be retained in the public sector. The MOH through its policies on private sector employment should seek to exercise control over this process. Some policy options are discussed in Section VI. An initial set of policies addressing the issue need to be finalised during 2003 and with it a revamping of the career system within the public service.

15.Introduce a mechanism to create higher differentials in pay between different

categories of public staff and move towards lifting public sector salaries into a better relationship to private sector incomes.


VIII. MONITORING AND EVALUATION A. Protocols for Monitoring Implementation Achievements

The medium-term plan is intended to provide, firstly, a set of objectives over a ten-year period and to provide guidance for year-to-year annual planning of HR activities and initiatives.

The purpose of this medium-term plan and the annual HR plan is, as stated earlier, to improve the foundation for good management and improved health service performance. It has been constructed, as was the 1996 master plan, from limited available data on past performance. As a consequence, the uncertainties which can influence effective implementation are much higher than can be anticipated for future medium-term plans. It is, as a result, necessary to review and amend the medium-term plans at appropriate intervals. It is likely that these intervals will be approximately two years. The medium-term plan sets out, first of all, a set of specific objectives to be achieved by the end of the medium term for staff numbers, staff training, and institutional staffing and how this might be distributed across the country.

It also sets out a series of developmental actions which need to be introduced during the course of the medium term, together with proposals for relevant policy changes introduced at the same time to support the intentions of the implementation plan.

The annual HR planning process will use the medium-term plan to establish, on a year-to-year basis, appropriate activities to meet the objectives of the ten-year plan. It is the achievements on a year-to-year basis which will provide the essential input to a review of the medium-term plan. The normal procedure will be to compare the achievements over the two-year period against the pre-determined objectives and, where there has been under-achievement, assessing the causal factors and judging whether appropriate corrections can be made in the rest of the plan period to achieve the objectives of the medium-term plan and/or on the basis of new information to reset the objectives of the medium-term plan. At the same time, a new medium-term plan extending for a further two years beyond the existing plan would be developed. The outcome of this process will be to provide new guidelines for the next annual plan in line with the new terms for the medium-term which is constantly rolling forward to maintain a ten-year horizon.


To support this process, the personnel/HR information system will need to be reassessed, revamped and expanded to meet the needs of HR planning and management and human resource development.

B. Specification of Important Progress Events

It can be anticipated that important events (milestones) will be added during the course of producing the final medium-term plan document. Some initial milestones to be considered are as follows: 1. HR information system assessed, upgraded and HR information

updated; 2. the introduction of an annual HR planning process; 3. the introduction of workload-based staffing norms across all

institutions and their use for annual planning; 4. the successful expansion of training institutions to meet staff

production as specified in the objectives; 5. measurable change in the distribution of skills in the workforce; 6. the creation of HR units or elements in the centre, regions and

districts; 7. measurable redistribution of staff in line with need; 8. fully operational computerised HR information system; 9. the introduction and use of performance indicators across all

regions; 10. detailed programme of hospital and primary care centre expansion

determined. C. Process for Annual Evaluation and Replanning of

Activities

This process is an essential ingredient for ensuring that the long-term plan and the medium-term plan continue to be useful vehicles for management development and change. Historically, in many countries the HR planning process has been isolated from the annual health service planning and often when incorporated in that process is not included in such a way as to make the interaction between HR plans and health plans viable.

To address this problem in Nepal, it is proposed that the process of annual HR planning is undertaken in parallel but slightly ahead of the health planning process to provide the health planners with a working framework for developing health plans and interacting more effectively with the realities of HR training, recruitment and deployment. An outline schedule of activities relating to an annual HR plan and linking into the annual fiscal process in the government is included as Appendix G.


APPENDICES


1

Policy groupprovides policy

direction for HRworking group

2

3

5 day H.R.strategic planning

Workshop

Key resultsreviewed withpolicy group

4

Consultant teamprepares initial

draft planDept of Health

reviews and modifies draft

5Dept submitsdraft plan for

ministryapproval

6

Strategic planused to guide

annual planningdecisions

7

Chairman-Health SecretarySpecial Secretaries /MoHDirector General /DHS

Vice Chancellor-BPKHISDirector-I.O.M.

Chief, PPM &FAD /MoHDirector, HIMDD /DHS

Chief, Drug Ad.,Qual.Ctl,Ayurved /DHS

WHO /GTZ Experts

Participants fromMin of HealthDept of Health

Nat Plan CommMin of Finance

IOMGovt. Med CollPriv. Med CollMin of EducWHO/GTZ

Appendix A. PROCESS FOR PREPARING STRATEGIC HR PLAN FOR THE HEALTH SECTOR

Kathmandu 28 November 2000

58


Appendix B. POLICY GROUP AND WORKING GROUP PARTICIPANTS

POLICY GROUP 1. Mr Padam Prasad Pokhrel, Health Secretary, MOH 2. Dr D.P. Manandhar, Special Secretary, MOH 3. Dr S.N. Aryal, Special Secretary, MOH 4. Dr Sekhar Koirala, Vice-Chancellor, BPKHIS, Dharan 5. Dr B.D. Chataut, Director General, DHS 6. Dr S.P. Bhattarai, Chief, PPM & FAD, MOH 7. Dr Benu Bahadur Karki, Director, HIMDD 8. Professor P.C. Karmacharya, Director, Institute of Medicine 9. Dr Asfaq Seikh, Chief, Drug Administrator 10. Dr S.S. Tiwari, Chief, Quality Control Section 11. Mr Iswar Bahadur Shrestha, HSD Expert, GTZ 12. Mr Laxman S. Paudel, Section Officer, Department of Ayurved 13. Mr Rishi Ram Khadka, Coordinator 14. Dr A.M. Das, Acting WR, WHO 15. Dr S.K. Upadhyay, NLO, WHO 16. Dr P.T. Jayawickramarajah, ME-HRH, WHO WORKING GROUP 1. Dr B.B. Karki, Director, HIMDD 2. Dr Sudhamshu Sharma, Rector, BPKHIS 3. Dr Kishor Raj Pandey, Asst. Med. Director, Nepal Medical College 4. Mrs Kamala Tuladhar, Asst. Dean, Institute of Medicine 5. Dr S.S. Tiwari, Chief, Quality Control Department 6. Mr Ishwar Shrestha, HSD Expert, PHCP/GTZ 7. Mr Raghu Ghimire, HRD Expert, PHCP/GTZ 8. Ms Gyanu Basnyat, Nursing Officer, HIMDD 9. Ms Durga Gurung, M/C Training Officer, NHTC 10. Mr Radha RamanPrasad, Sr. Drug Admin., Department of Drug Administration 11. Dr Dan Bahadur Adhikari, Section Officer, MOE 12. Mr Laxman Sharma Poudel, Section Officer, Department of Ayurved 13. Mr Keshab Prasad Acharya, Section Officer, MOH 14. Mr Prem Kumar Shrestha, Section Officer, MOH 15. Mr Bharat Bahadur Raut, Section Officer HIMDD 16. Mr Hemanta Raj Nirula, Accounts Officer, DHS 17. Mr Dillip Lamichhance, Section Officer, DHS 18. Ms Padma Mathema, Under Secretary, National Planning Commission 19. Dr S.P.Bhattarai, Chief, PPM & FAD, MOH 20. Dr A.M. Das, Acting WR, WHO 21. Dr P.T. Jayawickramarajah, ME-HRH, LTS/WHO 22. Mr Rishi Ram Khadka, Coordinator, HRH Projection 23. Mr Rudra Thakuri, Secretary, P & FAD/WHO 24. Mr Silas Rai, Secretary, HIMDD/WHO 25. Ms Geeta Amatya, PA to Director, HIMDD FACILITATORS 1. Mr P. Hornby, Senior Research Fellow, Keele University, UK 2. Ms S. Ozcan, Resesarch Associate, Keele University, UK


Appendix C. PERSONNEL CATEGORIES USED IN THE PROJECTION MODEL

Projection Model

Personnel Categories Description

Medical Specialist

Includes all medical officers with p.g. qualification

Medical Officer

Includes only those doctors with 5 years basic qualification, but no recognised p.g. training

Integrated medical Officer Doctors with Ayervedic training combined with medical officer training

Dental Surgeon

Includes all those with 4-4.5 years Bachelor Degree in dentistry and/or with p.g. qualification

Pharmacist

Includes all those with 4 years Bachelor Degree in pharmacy

Ass’t Pharmacist

Includes only with SLS degree with 1.5-2 years certificate course in pharmacy

Nurse (certificate/staff) Includes only SLC holders with 3 years nursing training ANM (Auxiliary Nurse Midwife) Includes only SLC holders with 18 months-2 years midwifery

training Graduate Nurse Includes only certificate level nurses with 3 years working

experience plus 2 years additional nursing training and includes SLC holders with 4 year graduate degree in nursing and includes nurses with p.g. degree

Medical Technologist Includes only graduate degree holders on medical lab. Lab Technician/Assistant Includes only those with 10/10+2 years schooling with 1.5-2

years lab. tec. Training Radiographer Includes only SLC holders with 3 years training in radiology Assistant Radiographer Includes only those with 10+2 years schooling or SLC with 1.5

years training in radiology VHW/MCHW Includes only those with 8 years of schooling with 3 months

training AAW+AHW Includes only secondary school graduates with 15 months trainingHealth Assistant/Kaviraj/ Hakim Includes only those with 10+2 years schooling or SLC holders

with 2 years training Allied health occupations Includes only graduate/2 years vocational school degree holders Allied non-medical professionals Includes only gradauate/vocational degree holders (e.g. engineers,

statistician, economist, lawyer, etc.) Manager Includes those with university degree in medicine/ public health

and several other areas. Refers to directors, chief officers, etc. Skilled support staff Includes only primary/secondary school graduates with very basic

additional training in several areas (e.g. sanitarian, mechanics, dark room assistants, etc.)

Other support staff Includes those with no specific education (e.g. cleaners, gardeners, drivers, etc.)


Appendix D. PROJECTED TRAINING REQUIREMENTS TO MEET STAFFING OBJECTIVES

Total Total Year 2003 Number of entrants to training Expected Intake Total intake Total Intake

Category Recruits already intake required in Losses in required to meet 2003

Required in already in YEAR5 Training in period 2003/2017 to

2003-2017 Training Training 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2,017 2003-2017 2004-2017 requirements 2017

Medical Specialist 1,225 177 71 70 80 90 90 100 105 110 110 120 120 120 (120) (120) (120) 61 1,110 1,181 1,541

Medical Officer 1 2,448 3,238 675 90 70 60 40 40 40 40 40 40 (40) (40) (40) (40) (40) 147 467 1,142 1,342

Integrated Med.Officer 57 83 15 0 0 0 0 0 0 0 0 0 0 0 0 0 0 6 0 0 15

Dental Surgeon 2,013 500 120 130 130 150 180 200 200 220 250 250 (250) (250) (250) (250) (250) 201 1,714 1,834 3,084

Pharmacist 477 68 28 28 28 40 40 50 50 50 50 60 60 (60) (60) (60) (60) 48 456 484 724

Assistant Pharmacist 505 23 15 25 35 35 40 45 50 50 50 50 60 70 70 (75) (75) 101 583 598 748

Nurse (certificate/staff) 6,088 1,815 730 650 550 550 500 450 400 400 499 500 500 500 (500) (500) (500) 1,218 5,490 6,220 7,720

ANM 2 14,014 1,523 1,050 1,100 1,150 1,150 1,200 1,300 1,400 1,500 1,550 1,600 1,650 1,700 1,800 (1800) (1800) 2,803 15,294 16,344 19,944

Graduate Nurse 1,685 286 82 100 100 120 130 150 160 180 190 210 220 (220) (220) (220) (220) 169 1,568 1,650 2,530

Medical Technologist 184 36 6 15 15 15 20 20 20 20 20 20 20 (20) (20) (20) (20) 37 185 191 271

Lab Technician/Assistant 682 1,974 1,128 0 0 0 0 0 0 0 0 0 0 0 0 (0) (0) 170 0 1,128 1,128

Radiographer 653 18 4 20 30 40 50 60 80 80 100 100 120 120 (120) (120) (120) 163 798 802 1,162

Assistant Radiographer 387 72 15 15 20 20 30 30 35 35 40 40 50 50 50 (50) (50) 97 412 427 527

VHW/MCHW 3 -285 45 450 0 0 0 0 0 0 0 0 0 0 0 0 0 (0) 0 0 0 450

AAW/AHW 2,461 4,914 4,800 0 0 0 0 0 0 0 0 0 0 0 0 0 (0) 615 0 4,800 4,800

Health Assistant/Kaviraj/Hakim 251 225 90 50 40 0 0 0 0 0 0 0 0 (0) (0) (0) (0) 63 89 179 179

Allied Health Occup'n 4 294 - - N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A - - - -

Allied non-medical Profession'l 190 - - N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A - - - -

Manager 206 - - N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A - - - -

Skilled Support Staff -366 - - N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A - - - -

Other Support Staff 9,114 - - N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A - - - -

Total 42,283 14,997 9,279 2,293 2,248 2,270 2,320 2,445 2,540 2,685 2,899 2,990 3,090 3,150 3,230 3,255 3,255 5,898 28,165 36,979 47,949

Note1: the intake for medical specialists comes from the medical officer category. A correction has been made in the medical officer training intake to allow for movement of existing medical officers to the specialist grade Note 2. Some of the intake will come from existing VHW/AHWs. Note 3: Training for this category to be discontinued Note 4: Certain categories of staff are not included in the training because the training is either not controlled by the MOH or no training is required. Note 5: The total annual training requirement includes trainees who will not graduate by 2017


Appendix E. SUMMARY OF KEY DATA ON HEALTH SECTOR CHANGES YEAR YEAR2003 2017 Projection years = 14

DEMOGRAPHIC INDICES24,228,636 33,083,801 Total population

------ 2.20% Assumed average annual % change in the population12% 20% Assumed % of population in urban areas

------ 6.00% Calculated average annual % change in urban population------ 1.60% Calculated average annual % change in rural population

GROSS DOMESTIC PRODUCT and EXPENDITURE ASSUMPTIONS------ 6.50% Annual average rate of change in gross domestic product (GDP)

2.10% 2.10% Total recurrent public sector as % of GDP16.10% 16.10% Recurrent health expenditures as % of public sector76.20% 70.00% Personnel expenditures as % of public health sector

------ 1.50% Assumed annual real change in health worker salaries (unweighted)------ 23% Calculated average total change in real health worker salaries (unweighted)

ESTIMATED ECONOMIC FEASIBILITY OF PROJECTED REQUIREMENTS SCENARIO------ 5.90% Calculated sustainable average annual change in expenditures------ 5.90% Assumed average annual change in expenditures------ 4,429.80 Calculated target year cost of health personnel (000,000)------ 3,898.50 Calculated target year funds available for personnel (000,000)------ 114 Calculated Target-Year costs as % of projected T-Year funds (near 100% is best)

PRIVATE SECTOR ESTIMATES AND ASSUMPTIONS------ 2.60% Calculated average annual change in private sector beds

3,804 5,159 Number of private sector bedsPERSONNEL INDICES

694 456 Population per health worker14 22 Health workers per 10,000 population

34,887 72,519 Total health personnel included in scenario------ 5.40% Average annual % change in health personnel

2 4.5 Number of public sector nursing staff per doctor0.9 1.9 Number of public sector auxiliary & assistant nurses per qualified nurse

76% 71% % of all health workers in public sector------ 91.70% % of all public sector personnel in clinical locations------ 2.20% % of all health workers in academic & training locations------ 3.70% % of all health workers in non-clinical public health

INSTITUTIONAL INDICES0.4 0.4 Total public and private beds per 1000 population

8,501 13,944 Total number of hospital beds55.30% 63.00% % of beds in the public sector

283 284 Number of public sector hospitals17 31 Average beds per public sector hospital

------ 3.60% Calculated average annual change in total number of beds HEALTH SYSTEM PRODUCTIVITY

445,490 869,002 Total hospital discharges18 26 Hospital discharges per 1000 population

70% % of discharges from public sector hospitals73% 80% Average occupancy rate in public hospitals

4 Average length of stay in public hospitals (days)53 69 Average discharges per bed-year in public hospitals


Appendix Fa. PUBLIC SECTOR INCOME ESTIMATES AND ASSUMPTIONS The working group reviewed the potential for real salary cost increases (i.e. not including any salary changes to adjust for inflation) to make public sector salaries more competitive with private sector salaries. Their recommendation of an “across the board” increase averaging 1.5% per year is financially viable with the proposed growth of public sector staffing. The results are shown in the table below. It does not, however, address the other issue of achieving a satisfactory pay differential between the highest and lowest grades of staff. Appendix ?b (not developed by the working group) explores one option for changing the pay differentials over the seventeen-year period within the financial constraints of the public health sector. Year 2000 Relative Annual % Year 2017 % change Average income real income average FTE over annual income (low=0.8) change annual income period Medical specialist 123,500 2.4 1.5 159,071 29% Medical officer 104,000 2.0 1.5 133,954 29% Dental surgeon 104,000 2.0 1.5 133,954 29% Pharmacist 104,000 2.0 1.5 133,954 29% Asst. Pharmacist 63,700 1.3 1.5 82,047 29% Nurse(certif./staff) 76,050 1.5 1.5 97,954 29% ANM 76,050 1.5 1.5 97,954 29% Graduate nurse 97,500 1.9 1.5 125,582 29% Medical Technologist 97,500 1.9 1.5 125,582 29% Lab technician/Assist. 63,700 1.3 1.5 82,047 29% Radiographer 97,500 1.9 1.5 125,582 29% Asst. radiographer 63,700 1.3 1.5 82,047 29% VHW/MCHW 63,700 1.3 1.5 82,047 29% AAW/AHW 63,700 1.3 1.5 82,047 29% Health Asst./Kaviraj/Hakim 76,050 1.5 1.5 97,954 29% Allied health occup. 97,500 1.9 1.5 125,582 29% Allied non-med. prof. 97,500 1.9 1.5 125,582 29% Manager 148,400 2.9 1.5 191,142 29% Skilled support staff 63,700 1.3 1.5 82,047 29% Other support staff 53,300 1.0 1.5 68,651 29% Note: Base year used for calculation is 2000


Appendix Fb. EXAMPLE OF PAY DIFFERENTIAL DEVELOPMENT

To change the pay differentials between different cadres of staff requires significant differences in real salary cost increases between the cadres. One example is shown in the table below which over the seventeen years of the plan period will change the differential between the highest and lowest paid from 2.95/1 to 5.0/1 while allowing a real increase for all staff. Year 2000 Relative Annual % Year 2017 Relative % change average income real income average income over annual income Year 2000 change annual income Year 2017 period Medical specialist 123,500 2.4 3.5 221,642 3.9 79% Medical officer 104,000 2.0 2.8 166,309 2.9 60% Dental surgeon 104,000 2.0 2.8 166,309 2.9 60% Pharmacist 104,000 2.0 2.1 148,071 2.6 42% Asst. Pharmacist 63,700 1.3 1.5 82,047 1.4 29% Nurse(certif./staff) 76,050 1.5 1.5 97,954 1.7 29% ANM 76,050 1.5 1 90,066 1.6 18% Graduate nurse 97,500 1.9 2.1 138,817 2.4 42% Medical Technologist 97,500 1.9 2.1 138,817 2.4 42% Lab technician/Assist. 63,700 1.3 1.5 82,047 1.4 29% Radiographer 97,500 1.9 2.1 138,817 2.4 42% Asst. radiographer 63,700 1.3 1 75,440 1.3 18% VHW/MCHW 63,700 1.3 0.8 72,940 1.3 15% AAW/AHW 63,700 1.3 1 75,440 1.3 18% Health Asst./Kaviraj/Hakim 76,050 1.5 2.1 108,277 1.9 42% Allied health occup. 97,500 1.9 2.1 138,817 2.4 42% Allied non-med. prof. 97,500 1.9 2.5 148,358 2.6 52% Manager 148,400 2.9 4 289,068 5.0 95% Skilled support staff 63,700 1.3 1 75,440 1.3 18% Other support staff 53,300 1.0 0.8 60,519 1.0 14% Note: Base year used for calculation is 2000


Appendix G. ANNUAL HR PLANNING (OUTLINE SCHEDULE) This outline sets out the steps of an annual HR planning process linked to annual health service planning. It is likely to require four to five months to complete. Month 1 Produce comparison of current HR objectives for year against achievement (i.e. numbers in training and in- service; distribution; performance and expenditure. Forecast year end outcome and assess causes of under- and over-achievement. Month 1 Produce overall targets for staff expansion and training in coming year in line with medium-term plan and current performance. Month 2 Consolidate and review bids from regions and

districts and make initial determination of priorities in post creation and projected distribution of staff and training. Month 3 Assess likely HR supply situation for coming year and explore possible policy options for changing requirement/ supply imbalances. Month 3 Quantify HR budget requirements additional to current year for next year training, new staff and salary changes and test feasibility. Month 3 Submit overall proposals for posts, staffing and training to Minister for review. Month 4 Revise staffing and training plans arising from ministerial/cabinet decisions and agree distribution of new posts and priorities for staffing. Month 5 Produce new projection for coming year of the distribution of new posts and staff supply and submit procedures and priorities for post filling to the personnel division. Month 5 Confirm target for pre-service training and execute processes to secure candidates, training places and funding.


Appendix H. Sources of Data and Information used in preparation of this document:

SN Institution/Document Remarks 01 Long Term Health Plan, MOH 02 Human Resource for Health,

Master Plan, 1996

03 Nepal Medical Council from unprocessed file 04 The 10th Plan 05 Central Bureau of Statistics, NPC 06 Nepal Population Report, 2002,

Ministry of Population and Environment

07 Center for Technical Training and Vocational Education Printed loose sheets

08 Birendra police Hospital 09 Birendra Military Hospital 10 Health Economics Section/MOH 11 Institute of Medicine Profile 2001 12 Association of Private Medical

Hospitals in Nepal Through data collection, supported by

WHO 13 Nepal Dental Association 14 Nepal Medical Association Doctors’ directory, 2002 15 Human Resource Development

Information System (HuRDIS)/DHS

16 Nepal Dental Association, 2002 and Nepal Oral Health Society Web site

17 Nepal Christian Hospitals Association

18 Nepal Netra Jyoti Sangh Loose sheet


POLICIES FOR THE DEVELOPMENT & DEPLOYMENT

OF MEDICAL SPECIALISTS IN NEPAL

(A complementary report to the Strategic Plan for Human Resources for Health

2003-2017)

June 2003

Submitted to the Ministry of Health by:

Peter Hornby Raghu Ghimire

prepared under the technical assistance of Health Sector Support Programme-GTZ, Nepal


CONTENTS Page Introduction 3 The Current Situation 3 Current Public Sector Specialist Staffing Levels 4 The Projected Change in Hospital Beds 5 Projected Distribution of Specialties by 2017 6 Requirements for Public Health Specialists 8 Implications for Specialists of the Growth in the Health Sector 8 Training Requirements for Specialists 13 Managing the Growth in Training 14 Policy Requirements 15 Follow-On Activities 15 Appendices: 17 Appendix A. Current Distribution of Specialists 17 Appendix B. Discussion Group Meeting Participants 18 Appendix C. A Scenario of Bed Projection for District Hospitals in Nepal to the year 2017 19 Appendix D. Projected Maximum and Minimum Intake Requirements for Specialists 22

TABLES 1. Summary of Distribution and Deployment of Specialists 3 2. Projected Change of Public Sector Health Service Facilities 4 3. Scenario of Projected Growth in District Hospitals 5 4. Distribution of Specialties by District Hospital Size 6 5. Proposed Distribution of Specialties by Zonal Hospital Size 7 6. Distribution of Specialties in Regional/Central/Teaching Hospitals 8 7. Specialist Requirements in District Hospitals 9 8. Proposed Zonal Hospital 2017 Specialist Requirements 10 9. Projected Specialist Requirements in Regional/Central/Teaching Hospitals and Public Health 11 10. Projected Maximum Specialist Requirements to 2017 for the Health Sector 12 11. Projected Maximum Specialist Training Requirements to 2017 13

FIGURE 1. Range of Annual Specialist Training Intake Requirements 14


Introduction The growth of medical training institutions in Nepal, combined with a lack of a coherent development strategy, has led to a relatively uncontrolled production of new medical specialists. This is not necessarily undesirable so long as the registration and qualification processes are rigorous and enforced. However, over the last ten years, their production has led to a large number of specialists working primarily in the private sector and located predominantly in Kathmandu. The consequence is that much of the population of Nepal gains little or no benefit from these highly skilled medical specialists. The strategic human resource (HR) plan for the health sector provides an initial framework for developing a career and deployment process. This has the potential for creating a more widespread accessibility to specialist services. One major difficulty in doing this is the lack of a strategic health service development plan to describe growth both in the public sector and in the private sector. Consequently, the size of growth in health institutions and the timing of the growth remain uncertain. Some estimates of the overall growth of institutions of a particular type were made by the working group responsible for the strategic HR plan building on priorities expressed in the tenth plan. However, the exact timing for the growth of particular institutions within the fourteen-year time span has not been specified. A development plan for these institutions is suggested by the author of this paper but it has no official sanction. It must be reviewed by officers of the Ministry as they determine construction priorities. This special report has been prepared at the request of the Ministry of Health, especially by the then Honourable Minister and the Planning Chief. The Current Situation There are thirty main medical specialties in which there are qualified specialists available in Nepal. Within these main specialities, there may also be specialists with sub-specialty skills. However, these are not documented. A full list of the specialties, together with the current distribution of specialists is shown in Appendix A. The number of current specialists and their distribution between the public and private sector has been estimated from information available in HuRDIS and the professional registers. There is clearly some uncertainty as to the total number of specialists who are still practicing and it has been suggested that some of those working in the public sector may also be engaged in some private sector activity.


Table 1. Summary of Distribution and Deployment of Specialists

Number of Different Specialties 30 Number of Specialists 1,544 Number of Specialists in public sector 363 (23.5% of total) Number of Specialists in private sector 1181 (76.5% of total) Number requiring hospital beds 1,227 (253 in public sector)

The distribution of registration addresses and the predominant location of tertiary hospitals in Kathmandu indicates that the great majority of specialists are located in Kathmandu with a small number in two or three of the major towns and with some public sector specialists located in zonal and regional hospitals. Nevertheless, it is clear that the availability of specialist services is predominantly in Kathmandu. Current Public Sector Specialist Staffing Levels The level of required specialist staffing is dependent on a number of variables. These are:

• Intensity of bed utilisation • Facilities and technology • Bed turnover rates • Population, demography and epidemiology • Availability of support staff • Types of medical intervention employed • Availability of funds • Health priorities

The situation will vary from speciality to speciality and will depend, over time, on the health priorities in the public sector. While this will also have some impact on the private sector, growth in the sector is driven more by the willingness and ability of the population to pay for particular medical interventions. At this time there are no specialists in district hospitals. All public sector specialists are in zonal, regional or central hospitals, although predominantly in the central and tertiary hospitals. The current and projected future requirements for beds in the public sector to 2017 (the strategic plan period) are shown in Table 2.


Table 2. Projected Change of Public Sector Health Service Facilities

Number Proposed % Total beds Proposed %

Type of Facility in For Change in beds for Change 2003 2017 2003 2017 Speciality L.Stay hospitals 5 5 0% 275 544 98% Regional/Central/Teaching hospitals

10 10 0% 1,860 2,718 46%

Zonal hospitals 10 10 0% 720 1,426 100% District hospitals 67 67 0% 1,030 3,227 213% Health centres with beds 191 191 0% 573 498 -13% Health posts 710 617 -13% - - - Sub-health posts 3,168 4,180 32% - - - PHC outreach clinics 13,700 23,724 73% - - -

TOTAL 17,776 31,958 80% 4,458 8,413 89%

For a country of the general level of development of Nepal, it would not be unreasonable to anticipate, for the specialties requiring hospital beds, that a ratio of one specialist to ten beds would exist. The ratio is currently 1:11 beds (i.e. 253 specialists/2855 beds). The private sector, including private for profit, non-governmental and mission hospital beds is somewhat better served with 947 specialists to 3804 beds (1:4), although it is more likely to be 1:5 beds as some specialists engage in outpatient practice only. The Projected Change in Hospital Beds The strategic HR plan working group proposed a growth in public sector beds from 4456 in 2003 to 8413 in 2017 (see also strategic plan document). The group anticipated that the private sector would also grow and set that growth at 2% per year in line with population growth. As a consequence, the overall number of private sector beds would increase from 3804 to 5021 beds. The total for the country, public and private, would increase from its current level of 8362 to 15,434 (i.e. about double current levels). The requirements for specialists will increase necessarily to accommodate:

1. the increase in the number of beds; 2. a reduced bed to specialist ratio; and 3. the expansion of many district hospitals to a sufficient size to justify the

inclusion of specialists.


District Hospitals

Appendix C provides a scenario of possible growth in district hospitals from the current level of fifteen beds in each district hospital. The projection in total growth is consistent with the strategic HR plan. The scenario has been constructed through a consideration of:

• population size and growth in the districts; • accessibility for the district population, both to the district hospital and/or to

adjacent district hospitals or higher level hospitals (zonal, regional and central).

Table 3. Scenario of Projected Growth in District Hospitals

No. of Beds No. of Hospitals District hospitals in 2017 with 15 4 25 18 40 to 50 31 60 to 75 13 300 1 Total public sector district hospitals 67 Note: For a detailed breakdown, refer to Appendix C. The remaining nine districts which are not listed with a district hospital have either a zonal, regional or central hospital or a mission hospital providing both primary and secondary hospital care. Zonal Hospitals There is no planned increase in the number of zonal hospitals but all will increase in size (see Table 2). It is proposed that these hospitals will exist in two different sizes of approximately 120 and 160 beds depending on population and access with five hospitals in the larger size. Regional/Central/Teaching Hospitals (including Long Stay and Specialist Hospitals This array of hospitals will not change in number but will increase in size with an associated increase in specialist requirements (see Table 2). Private Sector Hospital Expansion The information on the private sector is insufficient to make the same detailed projections of hospital growth. The strategic HR plan incorporates a projected overall growth for the private sector of 2% per year. This will be used, together with existing staff to bed ratios for the private sector and likely public sector growth to delineate the potential for growth in private sector specialist staff.


Projected Distribution of Specialities by 2017 The discussion group meeting held on 30 April 2003 (see Appendix B for list of participants) reviewed the potential for viable specialties in an expanded public sector. The expansion of the district and zonal hospitals adds new possibilities for deployment of specialists. These are shown in the following tables. The proposals contained in these tables come principally from the discussion group meeting with some revisions to provide consistency.


Table 4. Distribution of Specialties by District Hospital Size

Specialities District Hospital Size*

15 beds 25 beds 40-50 beds 60-75 beds General Medical X X X X Integrated medical X X X Specialist in General Practice X Obstetrics & Gynaecology X X General Surgery X Paediatrics X X Medicine X

* Patan Hospital excluded as its size (300 beds) equates more to regional hospital status than district hospital. The argument for the arrangement of specialties in Table 4 is as follows:

• The fifteen-bed hospital cannot justify the inclusion of specialists and the provision of care will be between a general medical officer and the new class of integrated medical officer providing some surgical expertise.

• For 25-bed hospitals, the clinical team is strengthened with the introduction

of a specialist GP practitioner. • As the number of beds increases the specialist service will expand to provide

the four foundation specialties of a district hospital. In all these districts, of whatever size, there will be only one specialist of the discipline represented with the implication that full specialist service will not be sustained as a 24-hour, 7-day a week service. The zonal hospital will provide a minimum of six specialties rising to eight specialties in the larger zonal hospitals and with both having some non-bedded specialist support. Table 5 sets out the proposed specialties.


Table 5. Proposed Distribution of Specialties by Zonal Hospital Size

Specialties Zonal Hospital Size

120 Beds 160 Beds Specialist General Practice X X Obstetrics & Gynaecology X X General Surgery X X Trauma & Orthopedics X Paediatrics X X Medicine X X ENT X X Ophthalmology X Anaesthesiology X X Radiology X X Pathology X X The regional/central/teaching hospitals (including long-stay and specialist hospitals) and incorporating the "super-specialist" services provided through Bir Hospital, Children's Hospital and the mental, ayurvedic and heart hospitals do not increase in number but do increase in size (number of beds). They will incorporate the full range of specialties, differing only in the number of specialists employed in each institutions. The specialties to be available in these institutions are as follows in Table 6.


Table 6. Distribution of Specialties in egional/Central/Teaching Hospitals

Medical Specialties Support Specialties Surgical Specialties

General Medicine

General Surgery Paediatrics Pediatric Surgery

Ophalmology Obstetrics/Gynaecology Dermatology Cardio-Thoracic Surgery Cardiology ENT Surgery Pulmology Urosurgery

Gastro-enterology Neurosurgery Nephrology Orthopaedic Surgery Neurology Plastic Surgery Psychiatry Dental Surgery

Anaesthesiology Radiology Pathology Endocrinology

Gerontology

Nuclear Medicine

Requirements for Public Health Specialists Additional to hospital requirements for specialists is that for specialists in public health. These will include specialists with expertise in:

• Public health (including specific disease specialists, e.g. malaria) • Epidemiology • Tropical medicine • Pathology

There are currently no technical arguments for how many public health staff will be required in the future. The total required will depend on:

• The nature and scale of public health services and activities and • The size of the population

For the purposes of this paper, it is assumed that existing public health staff will grow in line with population growth (i.e. 2% per year), a total of 32% over fourteen years. Implications for Specialists of the Growth in the Health Sector The variables that impact on the number of specialists required were identified in the section on current specialist staffing levels in this paper. These variables normally determine the number of beds and other facilities within an institution to support a particular specialty and the specialists who work in that area. The result is most commonly presented as the number of beds for a specialty and the numbers of beds per specialist.


The question of required beds per specialty and, within that, the number of beds needed to fully utilise one specialist was discussed at the discussion group meeting. There were no conclusions to be drawn from the observations made. Both topics did not seem to be issues that had been examined nor their significance explored in increasing the efficiency and effectiveness of the health care service. It will nevertheless become an issue that will require exploration in the future. In the short term, some assumptions have been made to allow a provisional calculation of the future requirement for specialists. District Specialist Requirements by 2017 The situation for district hospitals is relatively straightforward in that it is unlikely in the period to 2017 that more than one specialist of any specialty will be employed in a district hospital. Building on the projections of Tables 3 and 4, the proposed requirement for specialists at district level in shown in Table 7.

Table 7. Specialist Requirements in District Hospitals

Specialties Total Required for All District Hospitals with 15 beds 25 beds 40-50 beds 60-75 beds Total

General Medical Officer 4 18 31 13 66 Integrated Medical Officer 4 18 31 53 Specialist in General Prac. 18 18 Obstetrics & Gynaecology 31 13 44 General Surgery 13 13 Paediatrics 31 13 44 Medicine 13 13 Note: Patan Hospital requirements discussed in the section dealing with regional hospitals. The requirement shown in the table for medical officers, integrated medical officers and general practitioner (GP) specialists identifies only those who have primary responsibilities in the district hospital. Additional medical officers in training may also be added to the roster where necessary. Zonal Hospital Requirements The expansion of the zonal hospitals to between 120 and 160 beds offers little scope for choice in the bed allocations and specialty staffing. Although the bed allocation can vary, it is likely to be based primarily on thirty bedded units divided by gender except for obstetrics and gynaecology and ENT and specialist general practice, all of which would have a fifteen-bed allocation, reflecting some differences in the pattern of demand and, in the case of obstetrics and gynaecology, the single gender involved. All units should have at least two specialists. In the case of thirty-bedded unit, three specialists would be required to ensure reasonable specialist "cover". For zonal hospitals with 160 beds, two more specialties will be included (trauma and orthopaedics and ophthalmology, see Table 5). The development of these specialties,


together with other surgical specialties, will depend on the availability of adequate numbers of theatres and, as with the smaller zonal hospitals, an appropriate support structure in anaesthesiology, radiology and pathology. The proposed specialist requirements for 2017 are shown in Table 8. They represent one possible scenario of the distribution of beds and specialists and will undoubtedly need further review and revision in the light of perceived needs.

Table 8. Proposed Zonal Hospital 2017 Specialist Requirements

Zonal Hospital Size

Specialities 120 beds (5 hospitals) 160 beds (5 hospitals)

Specia;lty beds per hospital

Total Specialists for 5 hospitals

Specia;lty beds per hospital

Total Specialists for 5 hospitals

Specialist General Practice 15 10 15 10

Obstetrics & Gynaecology 15 10 20 10

General Surgery 30 15 30 15

Trauma & orthopaedics 20 10

Paediatrics 15 10 20 10

Medicine 30 15 30 15

ENT 15 10 15 10

Ophthamology 10 5

Anaesthesiology X 10 X 15

Radiology X 5 X 10

Pathology X 10 X 10

The ratio of specialists to beds is approximately 8.3 beds per specialty and not including specialists in support services. Regional/Central/Teaching Hospitals The projection for this group of hospitals poses far greater difficulties than for district and zonal hospitals. Other than policies and priorities in the tenth plan document, there is no special guidance available on how specialties should grow and be staffed. In these circumstances, to provide a "baseline" projection for the public sector institutions, it will be assumed that the distribution of beds among specialties in 2017 will follow the current distribution of specialists working in bedded specialties (see Appendix A). Furthermore, it will be assumed, in the absence of other information, that the beds to specialist ratio will be 1:8. The outcome of these assumptions is shown in Table 9. These can be grouped together with the projections for district and zonal hospitals to provide a total projected value for the public sector. It can be further combined with a


projection for the private sector to provide a total picture of likely requirements for specialists by the year 2017.

Table 9. Projected Specialist Requirements in Regional/Central/Teaching Hospitals and Public Health

Speciality % of all public sector specialists working in

specialty

Corrected % for bedded specialities

only

beds allocated (see table 2)

Specialists required @ 8

beds/specialist

Other Specialist requirements*

Total (including public health)

Obstetrics/Gynaecology 7.9% 17 604 76 76 Paediatrics 6.8% 15 520 65 65

General Surgery 5.2% 11 398 50 50 General Medicine 4.6% 10 352 44 44

Ophalmology 4.1% 9 314 39 39 Dental Surgery 4.1% 9 314 39 39

Anaesthesiology 8.3% X 37 37 Public Health 22.0% X 106 106

Orthopaedic Surgery 2.3% 5 176 22 22 Radiology 8.3% X 37 37

ENT Surgery 2.0% 4 153 19 19 Dermatology 1.8% 4 138 17 17

Pathology 11.0% X 49 49 Cardiology 1.7% 4 130 16 16 Psychiatry 1.4% 3 107 13 13

General Practice 1.2% X 5 5 Pulmology 1.2% 3 92 11 11 Urosurgery 0.6% 1 46 6 6

Gastro-enterology 0.6% 1 46 6 6 Cardio-Thoracic Surgery 0.4% 1 31 4 4

Epidemiology 0.4% X 3 3 Neurosurgery 0.4% 1 31 4 4

Tropical Medicine 0.4% X 3 3 Nephrology 0.3% 1 23 3 3

Pediatric Surgery 0.3% 1 23 3 3 Neurology 0.3% 1 23 3 3

Plastic Surgery 0.3% 1 23 3 3 Nuclear medicine 1.4% X 6 6

Endocrinology 0.6% X 2 2 Gerontology 0.3% X 1 1

Total 100.0% 3542 443 249 692

*Public health specialist growth at 2% per year. Hospital support services specialists in same proportion as now exists (see Appendix A). As stated earlier, there is little or no data to provide guidance on the likely growth in the private sector. Consequently, the same assumptions are used in this paper as in the


strategic HR plan. The assumption is that growth will keep in step with population growth (i.e. will grow by 32% by 2017). The results are shown in Table 10.


Table 10. Projected Maximum Specialist Requirements to 2017 for the Health Sector

Speciality Reg./Central/Teaching Hospitals & Public Health Zonal hospitals

District Hospitals

Total Public Sector

Private SectorTotal Health Sector as a

whole

Specialists required @ 8 beds/specialist

Other Specialist requirements*

Total (including public health)

Obstetrics/Gynaecology 76 76 20 44 140 181 321

Paediatrics 65 65 20 44 129 201 330 General Surgery 50 50 30 13 93 145 238

General Medicine 44 44 30 13 87 134 221

Ophalmology 39 39 5 44 121 165

Dental Surgery 39 39 39 119 159 Anaesthesiology 37 37 25 62 90 151

Public Health 106 106 106 24 130 Orthopaedic Surgery 22 22 10 32 68 100

Radiology 37 37 15 52 38 89 ENT Surgery 19 19 20 39 60 99 Dermatology 17 17 17 53 70

Pathology 49 49 20 69 6 74 Cardiology 16 16 16 49 65 Psychiatry 13 13 13 36 49

General Practice 5 5 20 18 43 34 77 Pulmology 11 11 11 34 45 Urosurgery 6 6 6 18 23

Gastro-enterology 6 6 6 16 22 Cardio-Thoracic Surgery 4 4 4 12 16

Epidemiology 3 3 3 12 15 Neurosurgery 4 4 4 12 16

Tropical Medicine 3 3 3 12 15 Nephrology 3 3 3 9 12

Pediatric Surgery 3 3 3 9 12 Neurology 3 3 3 8 11

Plastic Surgery 3 3 3 8 11 Nuclear medicine 6 6 6 0 6

Endocrinology 2 2 2 1 3 Gerontology 1 1 1 0 1

Total 443 249 692 215 132 1039 1509 2548

This projection of a requirement of 2548 specialists by the year 2017 is within 10% of the projections made in the strategic HR plan of 2003. This can be seen to be a satisfactory agreement, given the long time frame of the projection and the degree of uncertainty on which this projection is based. The more detailed analysis leading to a projection in this paper suggests that the projection values for specialists in this paper should be that used for planning rather than the more broadly based projection of the strategic plan.


Training Requirements for Specialists Training requirements emerge from, firstly, newly created posts and, secondly, from replacing existing specialists who no longer practice. From Appendix A, the existing number of specialists is 1544, increasing to 2548 in 2017, an increase of 1004 new specialist posts. Information on leaving rates (death, retirement, withdrawals and emigration) are not currently available. The strategic HR plan used an average value of 2.5% per year (i.e. a working life of 40 years) for all specialists. For those will become qualified over the next fourteen years, an estimated loss rate of 1% is suggested, in line with that proposed over the working life of specialists. For some categories of specialist, the numbers involved are too small to apply a statistical approach to estimates of future losses. The consequence of these assumptions overall is that if the proposed hospital and health service grows in the way suggested earlier in this paper, then the training requirements are as follows:

Table 11. Projected Maximum Specialist Training Requirements to 2017 Projected maximum new specialist posts = 1004 Expected losses from existing specialists = 41% x 1544 = 633 Expected losses from newly trained specialists = 14.9% x 1004 = 150 Total (maximum) to be trained = 1787 by 2017 Table 11 provides a statement of the maximum number of specialists required given the assumptions on growth and service contained in this document. At the other end of the spectrum would be the situation in which there was no growth in hospital capacity in either the public or private sector. In this situation, training requirements would be focused to a large extent on replacement of specialists who leave. In line with the calculation for the maximum requirement, this would imply a training requirement of 633 new specialists. To summarise, the requirement for new specialists over the period 2003 to 2017 and allowing for additional losses in those newly trained, is between approximately 680 and 1800, depending on health sector growth. Appendix D sets out the implications of this range of specialist development, specialty by specialty. It shows the number of doctors currently in training and the minimum and maximum training requirements over the remaining period of fourteen years. There are 108 people already in training. It can take approximately six years from entering the training process to achieving a full "super-specialist" or consultant status. To achieve the target for the period to 2017 will require intakes appropriate to the targets to be in place by 2011. For the lesser target, this would mean intakes of approximately seventy a year and for the higher target, starting at the current intake and increasing to approximately three times that number by 2011 and growing slowly thereafter. The range of intake options is shown in the following Figure 1.


Figure 1. Range of Annual Specialist Training Intake Requirements

0

50

100

150

200

250

300

350

2003 2004 2005 2006 2007 2008 2009 2010 2011 2112 2113 2114 2115 2116 2117

Year

Num

ber o

f Tra

inee

Rec

ruits

Minimum Recruits Maximum Recruits

Managing the Growth in Training Views on the number of doctors in training that could be successfully attached to a consultant specialist or a hospital specialist group and gain enough relevant experience were sought in the discussion group meeting. There was considerable variation ranging from one specialist to two trainees to one specialist or specialist group to six trainees. The variation was in part determined by the specialty involved and in part by individual judgements. As a generality, it could be suggested that four trainees could be sustained by a specialty team (i.e. two specialists). At any stage, there is likely to be 300 to 400 doctors in various degrees of experience and training for specialists. The number of existing specialists, both public and private, is sufficient to meet the training requirements, assuming that the requirements for training accreditation are sufficiently distributed at central and regional hospitals. Data on this aspect of training may well exist but was not available during the preparation of this paper. The object of the strategic approach in this paper is not only to prepare more specialists but also to ensure a wider distribution of highly skilled medical staff. At the moment, locations for specialist services are limited primarily to central and regional hospitals. The zonal hospitals averaging only seventy beds have limited opportunity for providing specialist services. Nevertheless, they could employ specialists in general practice, obstetrics and gynaecology, surgery and paediatrics, although in limited numbers but sufficient to provide training places for eighty to 100 medical officers in training over the ten zonal hospitals. It is proposed that the preparation of specialists will follow two main phases. The exact time required will vary from specialty to specialty. In the first phase, lasting up to three years, the medical officers in training will be attached to central and teaching hospitals in Kathmandu. On completion of this phase, they will be attached as senior medical officers in training at zonal hospitals for a period of up to two years. This will be followed by a final three-year period of training at the central/regional and teaching hospitals and will lead to a qualification as a specialist. This in turn will be followed by a mandatory posting to zonal or district hospitals (when expanded) of three years. It is at this point that specialists may compete for consultant posts in the regional and central hospitals. The difficulty in all this proposed deployment is in providing an environment in which the career movements of these staff are both accepted and acceptable. The primary issues that will need to be


addressed are:

• For financial, social and educational reasons, medical specialists do not wish to live in rural areas of Nepal.

• The deployment and promotion processes are not currently seen to be equitable in their application.

• The personnel mechanisms for ensuring timely movement of staff are not in place. • The rewards for following the recommended processes are not sufficient to discourage rapid

transfer to the private sector. It is perfectly possible to develop an ordered process for the movement of specialists and for those in training. However, the cornerstone for this development is a clear specification in the growth of hospital services and mechanisms that

• allow for its review and modification and • an information system combined with transparent operational policies that ensure timely and

equitable staff deployment. Policy Requirements To support the more managed development of medical specialists will require the introduction of new human resource policies or the clarification and possibly modification of existing policies. Given that this is a preliminary paper it is too early to specify precise policies without both further discussion and more data. However, it would appear that policy definition and/or clarification will be needed at a minimum to specify:

• the degree and conditions of guaranteed employment in the public sector; • service requirements to achieve full specialist qualification; • activity requirements to retain specialist accreditation; • the requirements to achieve entry into the promotion pool to consultant; • the extent of career guarantee; • the conditions and degree to which public sector specialists can undertake private work; • the benefit package associated with employment in disturbed locations; • the priorities for specialist training; and • requirements for achieving accreditation as training sites.

The purpose of these and related policies is to increase career certainty and ensure a more distributed specialist service. Follow-On Activities This paper is clearly a preliminary paper intended to provide an initial framework for specialist development. To translate this document into a Ministry guideline will require the following:

• Agreement on the growth and distribution of specialty beds. • Documented hospital development plans. • Agreed targets for beds per specialist in different types of hospital and for different


specialties. • Specific staffing ratios for staff in training to specialist. • Year-by-year detailing of new recruits to training by specialty. • Improvements of the HR management information system to enable monitoring and

management of staff movement. The medical specialists are so crucial to the successful development of the health service that significant investment in planning and managing this development process is well justified.


APPENDIX A: Current Distribution of Specialists

Speciality Current Supply

(estimate)

Public sector (F.T.E. * estimate)

Private Sector (F.T.E. estimate)

% of total specialists

% in specialty working in

public sector

% of all public sector specialists

working in specialty

1 Obstetrics/Gynaecology 204 29 176 13.2% 14.0% 7.9% 2 Paediatrics 177 25 152 11.4% 14.0% 6.8% 3 General Surgery 129 19 110 8.4% 14.7% 5.2% 4 General Medicine 118 17 102 7.7% 14.0% 4.6% 5 Ophalmology 106 15 91 6.9% 14.0% 4.1% 6 Dental Surgery 105 15 90 6.8% 14.0% 4.1% 7 Anaesthesiology 98 30 68 6.3% 30.6% 8.3% 8 Public Health 98 80 18 6.3% 81.7% 22.0% 9 Orthopaedic Surgery 60 8 51 3.9% 14.0% 2.3%

10 Radiology 59 30 29 3.8% 51.3% 8.3% 11 ENT Surgery 53 7 45 3.4% 14.0% 2.0% 12 Dermatology 47 7 40 3.0% 14.0% 1.8% 13 Pathology 44 40 4 2.9% 90.5% 11.0% 14 Cardiology 43 6 37 2.8% 14.0% 1.7% 15 Psychiatry 32 5 27 2.1% 15.5% 1.4% 16 General Practice 30 4 26 1.9% 14.0% 1.2% 17 Pulmology 30 4 26 1.9% 14.0% 1.2% 18 Urosurgery 16 2 13 1.0% 14.0% 0.6% 19 Gastro-enterology 14 2 12 0.9% 14.0% 0.6% 20 Cardio-Thoracic Surgery 11 2 9 0.7% 14.0% 0.4% 21 Epidemiology 11 2 9 0.7% 14.0% 0.4% 22 Neurosurgery 11 2 9 0.7% 14.0% 0.4% 23 Tropical Medicine 11 2 9 0.7% 14.0% 0.4% 24 Nephrology 8 1 7 0.5% 14.0% 0.3% 25 Pediatric Surgery 8 1 7 0.5% 14.0% 0.3% 26 Neurology 7 1 6 0.5% 14.0% 0.3% 27 Plastic Surgery 7 1 6 0.5% 14.0% 0.3% 28 Nuclear 5 5 0 0.3% 104.7% 1.4% 29 Endocrinology 2 2 0 0.2% 83.7% 0.6% 30 Gerontology 1 1 0 0.1% 83.7% 0.3%

Total 1,544 363 1181 100.0% 23.5% 100%

*FTE = Full Time Equivalent


APPENDIX B. Discussion Group Meeting – Production and Mobilisation of

Medical Specialist

Participants

Honourable Prof. Upendra Devkota, Health Minister

Mr.Mhendra Nath Aryal, Health Secretary

Dr. BB Karki Chief, Planning Division, MOH

Dr. LR Pathak, Act. Director General, DHS

Dr. Piyush Rajendra, Director, MD/DHS

Dr. Ram Prasad Shrestha, Focal Point, MOH

Dr. D.N.Gongol, National Institute of Medical Sciences

Dr. Manohar Lal Shrestha, Superintendent, Bir Hospital

Dr. Ashok Bajracharya , Sr.Consultant, Bir Hospital

Dr. Pawan Sultaniya, Sr.Consultant, Bir Hospital

Dr. Bhagawan Koirala, Director, Sahid Ganga Lal Heart Centre

Dr. D S Malla, Director, Maternity Hospital, Thapathali

Dr. Bimala Lakhe, Maternity Hospital, Thapathali

Dr. K D Joshi, Sr. Consultant, Bir Hospital

Dr. Bishnu Pandit, Chief, Curative Division, MOH

Dr. P B Thapa, Director, Kanti Children Hospital

Dr. Ranendra PB Shrestha, Sr.Consultant, Kanti Children Hospital

Dr. Sarala Malla, , Director NPHL, Teku

Dr. S R Acharya, Acting Director, Dept of Ayurveda

Dr. Bhupendra B Thapa, Director, Dept of Drug Administration

Dr. A Schrettenbrunner, Programme Manager, HSSP-GTZ

Mr. Ramjee Dhakal, Deputy Programme Manager, HSSP-GTZ

Mr. Raghu Ghimire, Programme Officer/HRD, HSSP-GTZ

Dr. Peter Hornby, Resource Person, University of Keele, UK

NHTC Hall, Kathmandu

30-Apr-03


APPENDIX C:

A Scenario of Bed Projection for District Hospitals in Nepal to the year 2017

District District Hospital Remarks Population 2001

Population 2016

% change

Existing beds in 2003

Bed requirement

by 2017 NEPAL 23,151,423 32,202,975 39 - -

Achham Bayalpata Hospital, Bayalpata-Achham not yet in operation 231285 302711 33 15 15

Bajura Bajura Hospital, Bajura 108781 148206 36 15 15

Manang Manang Hospital, Chame, Manang 9587 6590 -31 15 15

Mustang Mustang Hospital, Mustang 14981 22870 53 15 15

Baitadi Baitadi Hospital, Baitadi 234418 322418 38 15 25

Bajhang Bajhang Hospital, Bajhang 167026 223593 34 15 25

Dadeldhura Dadeldhura Hospital, Dadeldhura 126162 173797 40 15 25

Dailekh Dailekh Hospital, Dailekh 225201 304081 35 15 25

Darchula Darchula Hospital, Khalanga, Darchula 121996 164023 34 15 25

Dolpa Dolpa Hospital, Dolpa under construction 29545 40668 38 15 25

Doti Doti Hospital, Silgadhi, Doti 207066 263797 27 15 25

Gorkha Anppipal Hospiatal, Gorkha 288134 400561 39 15 25

Gorkha Gorkha Hospital, Gorkha 288134 400561 39 15 25

Humla Humla Hospital, Humla 40595 58067 43 15 25

Jajarkot Jajarkot Hospital, Khalanga, Jajarkot 134868 186755 38 15 25

Kalikot Kalikot Hospital, Kalikot 105580 142481 35 15 25

Mugu Mugu Hospital, Mugu under construction 43937 55206 26 15 25

Palpa Tansen Hospital, Palpa 268558 377332 41 15 25

Rasuwa Rasuwa Hospital, Dhunche, Rasuwa 44731 63039 41 15 25

Salyan Salyan Hospital, Salyan 213500 294860 38 15 25

Sindhupalchok Sindhupalchowk Hospital, Chautara 305857 420271 37 15 25

Taplejung Taplejung Hospital, Taplejung 134698 178686 33 15 25

Achham Achham Hospital, Mangalsen, Acham 231285 302711 33 15 40

Bhojpur Bhojpur Hospital, Bhojpur 203018 303809 50 15 40

Jumla Jumla Hospital, Jumla 89427 121134 35 15 40

Khotang Khotang Hospital, Khotang 231385 326490 41 15 40



Population 2016

% change


Bed requirement

by 2017

Panchthar Panchthar Hospital, Phidim, Panchthar 202056 287399 42 15 40

Parbat Parvat Hospital, Kusma, Parbat 157826 231564 47 15 40

Ramechap Ramechhap Hospital, Ramechhap 212408 310322 46 15 40

Sankhuwasabha Sankhuwasabha

Hospital, Khadbari, Sankhuwasabha

159203 226489 42 15 40

Sindhuli Sindhuli Hospital, Sindhuli 279821 384973 38 15 40

Solukhumbhu Solukhumbu Hospital, Phaplu, Solukhumbu 107686 155639 45 15 40

Terhathum Terathum Hospital, Terathum 113111 165304 47 15 40

Arghakhachi Arghakhachi Hospital,

Sandhikharka, Arghakhachi

208391 297686 43 15 50

Baglung Baglung Hospital, Baglung 268937 365986 36 15 50

Bardiya Bardiya Hospital, Gulariya, Bardiya 382649 564736 43 15 50

Dang Mahendra Hospital, Dang 462380 644380 39 15 50

Dhading Dhading Hospital, Dhading 338658 465862 38 15 50

Gulmi Gulmi Hospital, Tamghas, Gulmi 296654 429781 45 15 50

Lamjung Lamjung Hospital, Besisahar, Lamjung 177149 230071 30 15 50

Morang Rangeli Hospital, Morang 843320 1189966 41 15 50

Myagdi Beni Hospital, Myagdi 114447 153831 34 15 50

Pyuthan Pyuthan Hospital, Pyuthan 212484 281376 32 15 50

Rolpa Rolpa Hospital, Rolpa under construction 210004 279741 33 15 50

Rukum Rukum Hospital, Musikot, Rukum 188438 259186 38 15 50

Sarlahi Sarlahi Hospital, Sarlahi 635701 855680 35 15 50

Siraha Siraha Hospital, Siraha 572399 796650 39 15 50

Sunsari Sunsari Hospital, Inaruwa, Sunsari 625633 854869 37 15 50

Syangja Syangja Hospital, Syangja 317320 461972 46 15 50

Tanahun Bandipur Hospital, Tanahaun 315237 454654 44 15 50

Udayapur Udayapur Hospital, Gaighat, Udayapur 287689 416520 45 15 50

Dolakha Dolkha Hospital, Jiri, Dolakha 204449 288732 41 25 50

Dang Ayurvedic Chikitsalaya, Dang equivalent to District Hospital 462380 644380 39 30 50

Mahottari Jaleswor (P C) Hospital, Mahottari 553481 751924 36 25 60



Population2016

% change


Bed requirement

by 2017

Dhankuta Dhankuta Hospital, Dhankuta 166476 238382 43 15 75

Ilam Ilam Hospital, Ilam 282806 409400 45 15 75

Kapilvastu Prithivi Bir Hospital, Kapilvastu 481976 694936 44 15 75

Kapilvastu Shivaraj Hospital,

Bahadurgung, Kapilvastu

481976 694936 44 15 75

Nawalparasi Pi. Chandra

(Nawalparasi) Hospital, Nawalparasi

562870 830262 48 15 75

Siraha Lahan (Ramkumar

Umaprasad Memorial) Hospital,Lahan

572399 796650 39 15 75

Surkhet Surkhet Hospital, Surkhet 288527 415347 44 15 75

Bara Kalaiya Hospital, Bara 559135 749568 34 25 75

Makawanpur Hetauda Hospital,

Hetaunda, Makawanpur

392604 563880 44 25 75

Nuwakot Trisuli Hospital, Nuwakot 288478 408368 42 25 75

Rautahat Gaur Hospital, Rautahat 545132 749568 33 25 75

Rupandehi Bhim Hospital,

Bhairahawa, Rupendehi

708419 976330 38 25 75

Lalitpur Patan Hospital equivalent to Regional Hospital 337785 456527 36 150 300

Total 3210


APPENDIX D. Projected Maximum and Minimum Intake Requirements for Specialists

Speciality Current Supply

(estimate)

Maximum Specialist

Requirement

Likely Losses from Existing

Staff

Maximum Trainee Intake

Requirements to 2011

Presently in training

Maximum Trainee Intake requirements

2004-2011

Minimum Specialist

Requirement

Minimum Trainee Intake requirements

2004-2011

Obstetrics/Gynaecology 204 321 84 220 8 212 204 82

Paediatrics 177 330 72 248 7 241 177 71

General Surgery 129 238 53 178 14 164 129 43

General Medicine 118 221 48 167 7 160 118 45

Ophalmology 106 165 44 112 4 108 106 43

Dental Surgery 105 159 43 106 28 78 105 18

Anaesthesiology 98 151 40 103 3 100 98 40

Public Health 98 130 40 79 1 78 98 42

Orthopaedic Surgery 60 100 24 71 4 67 60 22

Radiology 59 89 24 60 2 58 59 24

ENT Surgery 53 99 22 75 3 72 53 20

Dermatology 47 70 19 47 4 43 47 16

Pathology 44 74 18 53 2 51 44 17

Cardiology 43 65 18 44 2 42 43 17

Psychiatry 32 49 13 33 3 30 32 11

General Practice 30 77 12 65 4 61 30 9

Pulmology 30 45 12 31 0 31 30 13

Urosurgery 16 23 6 16 2 14 16 5

Gastro-enterology 14 22 6 15 1 14 14 5

Cardio-Thoracic Surgery 11 16 4 11 1 10 11 4

Epidemiology 11 15 4 10 1 9 11 4

Neurosurgery 11 16 4 11 1 10 11 4

Tropical Medicine 11 15 4 10 1 9 11 4

Nephrology 8 12 3 8 1 7 8 3

Pediatric Surgery 8 12 3 8 2 6 8 2

Neurology 7 11 3 7 2 5 7 1

Plastic Surgery 7 11 3 7 0 7 7 3

Nuclear 5 6 2 3 0 3 5 2

Endocrinology 2 3 1 2 0 2 2 1

Gerontology 1 1 0 1 1 0 1 0

Total 1,544 2548 633 1,800 109 1,691 1,544 568

n e strategic plan for p human resources for health...

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