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Addressing the Global Nursing Shortage by Strengthening the Community Health Workforce

Author: Pratikshya Dhungana is a Senior Fellow with the Atlantic Fellows for Health Equity and a Community Health Program Lead at Nyaya Health Nepal. The opinions expressed here are her own.  All photos are used with permission from the author.

In March, Hampshire Hospitals in the United Kingdom welcomed 42 nurses to help fill the shortage they have in their hospital system. This is part of a pilot program that Nepal initiated with the UK National Health Service last year that allows nurses from the country to practice in the UK.  The system will continue to welcome additional nurses through the summer.

On face value, this seems like a good opportunity for the nurses who participate. They will earn significantly higher pay while helping the UK fill its nursing shortage. However, Nepal is already on the World Health Organization’s list of countries facing significant healthcare workforce shortages. It has less than 74,000 registered nurses to serve  its 26 million residents.  Over a third of its nurses have applied for licenses to practice abroad in countries such as the United States and the UK. 

These shortages are particularly marked in rural areas of Nepal. The country is ranked 4th in terms of dangers from climate change facing extreme variations of weather based on its mountainous topography. During the monsoon season, which starts in June, certain parts of the country become relatively impassable. There are pronounced gaps in healthcare between Nepal’s urban and rural areas. Cities such as Kathmandu have better healthcare, while rural regions often lack basic facilities, trained medical staff, and essential supplies. In addition to the nursing shortage, medical school graduates tend to choose to practice in urban areas, exacerbating the problem. 

Rural Nepalese face differences in health outcomes driven by these differences in access to care. Therefore, having a network of Community Health Workers (CHWs) who provide care within local communities is crucial. In Nepal, the CHW model has been very effective in working to bridge some of the wide gaps in healthcare access for the country. One example is the  female community health volunteer program (FCHV) in which women receive training in maternal and child health with support of the local primary care clinic. One FCHV can serve as many as 200 individuals in a year. Young mothers, many barely out of their teens, lean heavily on the FCHV, who serve as their lifelines, offering vital guidance on pregnancy, antenatal care, nutrition, and postpartum care, leaving no stone unturned. The broader network of  CHWs are also highly effective in assisting individuals with chronic illnesses manage their daily health needs. 

In 2018,  Nepal implemented a federalist government model, placing more power in the hands of local governments. Local governments work in partnership with non-governmental organizations to deliver care. These partnerships and increased focus on CHWs by local governments signifies a major step forward, signifying the growing wave of the success and importance of CHWs in providing healthcare at the local level. In this setup, community-based partners offer vital technical aid, using local knowledge and resources to recruit and train CHWs. At the same time, municipalities take on the task of funding CHW salaries and identifying their essential role in public health. This teamwork not only promotes collaboration between governmental bodies and healthcare institutions but also shows a joint dedication to enhancing community health. This collaboration showcases a combined process of delivering healthcare, utilizing local resources and knowledge to enhance community health results.  

One such organization working in partnership with local governments is Nyaya  Health Nepal (NHN). NHN is a non-governmental organization in one of the country’s poorest areas, Accham district. It operates a hospital in the area, Bayalpata Hospital, in partnership with the Ministry of Health. There have been several documented success stories. Take the case of one patient who faced a life-threatening pregnancy with a transverse baby position. One of the NHN nurses’s interventions ensured a timely cesarean section at Bayalpata Hospital, saving both the patient and her baby. Another pediatric patient from a remote village had a serious heart condition. A local healthcare worker taught and trained by NHN was able to intervene and refer the patient to the tertiary center in Kathmandu for proper care and  treatment. NHN’s CHWs are also trained in trauma care and clubfoot screening. They screen and refer the children with clubfoot to receive treatment at Bayalpata Hospital and assist patients with fall injuries. This highlights the importance of building healthcare facilities at the grassroots level that can both provide care independently and help bridge care to larger facilities when necessary. 

CHWs are clearly cost-effective mechanisms of delivering effective care. A pilot program initiated by NHN was found to be sustainable at a mere estimated cost of U.S.$3.05 per community health worker.  However, despite the low cost and documented success, CHW programs still face many potential challenges. Exploring how long it is feasible for the Nepal government to use the female community health volunteer program without full payment and social security coverage is one such issue. Nepal’s healthcare system struggles with securing funds, effective governance, and collaboration with investors. Limited financial resources, alongside political instability, have left the government unable to sufficiently invest in healthcare infrastructure and staff development. 

While local governments recognize the important role of CHWs, there is a worrying absence of acknowledgement from provisional authorities. Additionally, donors are pushing for the implementation of new interventions, overlooking the contributions of CHWs. It is important that maintaining CHW continuity takes priority over introducing innovative interventions. Insufficient support and funding limitations may risk the continuity of vital services, putting at risk the health and financial independence of both CHWs and the communities assisted by them.

Lastly, spreading awareness to marginalized communities in areas in which CHWs serve is critical, especially given the local governments expanded partnerships that will make such programs more widespread. Many individuals may be less likely to use the much needed service due to a lack of knowledge, concerns with trust, and other barriers to care that could be addressed with broader educational initiatives.

As Nepal continues to suffer from brain drain due to programs such as the UK’s NHS pilot and other pressures, it is more important than ever to support CHWs in Nepal. This program can allow Nepal to boost health outcomes, narrow healthcare gaps, and foster a wellness code across local communities despite external challenges. It is essential that there be continued focus on this important program given its potential to change the entire picture of healthcare delivery in Nepal, tackling access inequalities and encouraging broad, patient-focused care.  In the future, expanding awareness of the CHW to increase its scope and reach is paramount to continuing prior successes.

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