The crisis of physician well-being in Nepal: a multifaceted dilemma demanding urgent intervention

Abstract

MBBS doctor training began in 1978, and since then, Nepal has established 21 medical colleges [1, 2]. These colleges produce around 2000–2500 doctors annually, with ∼1200 doctors passing their national licensure test each year. Recently, the prime minister approved the establishment of two new medical colleges, and five more are in the planning stages [2]. Among the existing colleges, one is owned by the Nepalese army, while 16 are private and four are government-owned [2]. These statistics reflect the number of doctors in a land area of 147 181 km² with a population of ∼29 million. However, despite these numbers, the quality of doctors’ lives and healthcare delivery in the country are still neglected. The distribution of medical colleges is disproportionately concentrated in the capital and urban areas, resulting in a significant doctor–patient ratio discrepancy. In the capital, the ratio is 1:850, whereas, in rural areas, it is 1:150 000 [3]. This unequal distribution leaves rural populations devoid of quality healthcare [4].

The salary of a medical graduate (MBBS, Bachelor of Medicine, Bachelor of Surgery) ranges from Nepalese Rupee (NPR) 35 000–NPR 132 000 (equivalent to ∼$300–$1100) per month. In government hospitals, the salary scale for an MBBS doctor ranges from NPR 40 000–NPR 60 000 (∼$300–$500). Most MBBS doctors in the capital work >72 h per week. Additionally, Proficiency Certificate Level nurses in Nepal earn a monthly salary ranging from NPR 12 000 to NPR 20 000 (∼$100–$170) at the current exchange rate. In comparison, pilots in Nepal can earn an average of NPR 190 000–NPR 400 000 (around $1600–$3400) per month, while secondary-level teachers earn an average of NPR 35 000–NPR 40 000 ($300–$340) per month.

Data obtained from the Nepal police reveal that the average annual increase in suicides over the past 5 years in Nepal has been 7.2%. However, in 2021, the rate of increase spiked to 14%. With the increasing number of doctors, there is a rise in the incidence of burnout, depression, and suicide. Although physicians are more prone to burnout and depression, limited studies have been conducted in Nepal. A study conducted during the COVID-19 pandemic among 404 health workers reported a high prevalence of stress (28.9%), anxiety (35.6%), and depression (17.0%) [5]. Another study revealed a relatively balanced relationship between compassion satisfaction and compassion fatigue (burnout and secondary traumatic stress) among 174 Nepalese medical doctors, despite the high prevalence of compassion fatigue. A significant proportion of respondents (72.4%) reported experiencing burnout symptoms, while 77.6% of participants reported secondary traumatic stress [6]. Both studies highlight the importance of assessing the mental well-being of physicians. Although there are no national-level studies on the comparative prevalence of suicide among different professionals or the prevalence of suicide among physicians/health workers in Nepal, media reports indicate seven suicides among doctors recorded over a span of 2 years.

Several distressing incidents have taken place among healthcare professionals in Nepal, highlighting the criticality of prioritizing good mental health in the medical field. These include the suicides of a consultant psychiatrist and a senior neurosurgeon in July and October 2021, respectively. In March 2022, a third-year medical student tragically took their own life, followed by a medical officer (MBBS) in October 2022, who left a heart-wrenching letter expressing their desire not to live. Additionally, in December 2022, a resident passed away due to cardiac arrest, likely a result of a stressful work environment and long working hours. More recently, on 10 May 2023, a fourth-year dental student sadly ended their life, shedding light on the distress caused by mental harassment from teachers. On 1 June 2023, another sorrowful incident occurred involving the loss of a promising pediatric postgraduate resident, suspected to be connected to the postgraduate education selection process. These occurrences, spanning various career stages, underscore the critical need for prioritizing and supporting mental health.

The increasing suicide rates among medical professionals highlight the severity of burnout and depression in the healthcare sector. This rise is not solely attributed to professional stress or the COVID-19 pandemic but also influenced by various factors, including inadequate recruitment in government hospitals and a shortage of healthcare professionals despite the growing number of medical colleges. Paradoxically, there are both shortages of healthcare workers and underemployed or unemployed doctors in the country, revealing inefficiencies in resource distribution. Attacks on physicians are spreading like wildfire across the country, with these news headlines appearing on a monthly basis. Surgeons are particularly vulnerable, in both rural and urban areas. However, a comprehensive understanding of the challenges faced by different specialties and the impact of rural versus urban settings requires large-scale studies. Such studies would provide scientific insights and guide targeted interventions to effectively address violence against healthcare workers. The Nepal Medical Association, which aims to protect doctors’ rights, has been hindered by political interference in healthcare and medical education. Despite national and international suicide prevention efforts for the general public, there is a lack of national-level programs specifically addressing suicide among doctors.

Nepal’s physician crisis persists despite high doctor production. Although doctors are trained to save lives, they often fail to save their own. The healthcare system’s deplorable state drives more doctors to emigrate, creating a scarcity of skilled healthcare professionals [3]. According to the efficiency wage theory, productivity rises with pay, and paying physicians a standard salary is likely to motivate them to deliver high-quality care [7]. Violence against providers is rising as grievances intensify due to inadequate healthcare and insufficient protection of doctors’ rights. Challenges have worsened during the COVID-19 pandemic, burdening physicians in this resource-limited country. Government hospitals still have long waiting lists, disproportionately affecting rural patients. Limited rural healthcare staff increases workloads for health workers. Physicians feel trapped between the hubris of the general public and non-scientific, impractical policies.

To address these issues, vacant positions in government hospitals must be filled promptly, prioritizing physicians’ mental health. The government’s next challenge is addressing the brain drain by offering standard salaries, effective management, conducive environments, and reasonable hours, which are vital for the well-being and motivation of healthcare professionals. Initiatives inspiring professionals to stay in Nepal are needed to counter brain drain. The National Health Insurance Program requires attention from leaders to maintain its value. Controlled regulation of healthcare privatization can prevent degradation. Resilience training and professional programs are essential for students and healthcare workers. Healthcare leaders must engage with frontline staff and upgrade the infrastructure and quality of government medical colleges. Laws should guarantee the safety of medical personnel. Laws must guarantee medical personnel’s safety. This crisis demands global attention and necessitates a national study to evaluate burnout, depression, and suicide among healthcare professionals and develop strategies accordingly. Figure 1 outlines the current scenario, challenges, and effective strategies in Nepalese healthcare.

Figure 1

Unveiling the healthcare crisis: scenario, challenges, and effective strategies.

Open in new tabDownload slide

Funding

No funding was received.

Ethics and other permissions

Not applicable.

References

Author notes