A Doctor’s Decade in Nepal’s Healthcare System

 

(The article first appeared in Setopati )

This year marks a decade since I began my journey as a doctor in Nepal. From the remote hills of Achham to the operation theatres of Kathmandu and back to my hometown of Dang, the last ten years have been both personally rewarding and professionally insightful. I have worked at all levels of our healthcare system- from a rural hospital to a tertiary one - and what I’ve seen compels me to speak not only as a surgeon, but as a citizen concerned about the future of healthcare in Nepal.

Beginning in Achham

My first posting as a fresh MBBS graduate was in Achham district hospital, in the far western hills- a remote region plagued by social, economic and political disadvantage, where people have woeful access to health services. There, I experienced the stark realities of rural health firsthand: elderly patients living alone, malnourished children without parental care, and a health system stretched thin. A stethoscope was the only piece of modern equipment available to me and listening to the hearts and lungs of my patients to make sense of their ailment used to be my daily routine. More importantly, I made it a point to listen to their life stories, their hardships and the quiet desperation of social isolation and poverty. Many elderly patients presented with vague complaints like body ache at multiple sites, without any specific diagnosis. In such cases, treatment meant not only prescribing medicines, but also providing emotional support.

Many patients had to be referred to higher centers for better medical and surgical care; the nearest ones being Dhangadhi or Nepalgunj. It was an arduous journey that took over 10 hours, often worsening outcomes. Despite these limitations, Achham sharpened my clinical skills and deepened my empathy. I also completed Advanced Skilled Birth Attendant (ASBA) training which enabled me to perform cesarean sections- a critical skill in regions where maternal and neonatal deaths remain unacceptably high. In fact, in rural areas where specialist obstetrician care is still a far cry, ASBA trained MBBS doctors have been doing a remarkable job saving the lives of mothers and the newborns.

After two years in Achham, I moved to Dadeldhura hospital and later to Rapti Provincial Hospital, Dang; better-equipped institutions with more staffs and services. Here I deepened my involvement in obstetrics and minor surgical care. Eventually, I pursued a residency in General Surgery at Bir Hospital, one of the busiest tertiary hospitals in the country. It was a period of immense learning- across emergency rooms, operation theatres, ICUs and wards. I came to appreciate the scientific rigor and art of surgery in equal measure. Post-residency, I returned to Dang now as an MS general surgeon. I have since been performing elective and emergency surgeries daily, with a renewed sense of purpose and responsibility. Having come full circle- from a rural setting to advanced surgical practice- I now feel positioned to speak not just as a practitioner, but as a witness to Nepal’s evolving health system.

Reflections on Nepal’s health system

Across these years and locations, one lesson stands out: Nepal’s health system is uneven. Rural areas suffer from chronic shortages of skilled manpower, lack of equipment and poor infrastructure. It is no exaggeration to say that buildings exist, but services don’t. Patients exist, but doctors don’t. Geta Medical College of Dhangadhi is a case in point. Of course, there has been gradual improvement in this sorry state of affairs. For example, the Karnali region, the land once named for hunger and hardship, now produces specialist doctors; thanks to the tireless efforts of many who made possible the birth of Karnali Academy of Health Sciences (KAHS) in Jumla. But we must admit that the system is still heavily city-centric and the government’s incentive structure does little to motivate doctors to serve in remote areas.

To address this problem of manpower shortage in government health institutions, the Ministry of Health recently called for an additional 2100 doctors, nurses and health personnel based on a rigorous Organizational and Management (O & M) survey. But the Ministry of Finance balked citing budget constraints. It is deeply disheartening to see such clear, evidence-based proposals sidelined, especially while government funds flow unchecked into lavish projects that appear to serve political vanity more than public welfare.

If we are to improve health outcomes equitably, we must incentivize rural service- financially, professionally and personally. No doubt, the government should send more young doctors to rural postings- whether under scholarship bonds or as permanent Loksewa appointments. Even one year of rural medicine can be transformative. The first time I saw a mother walk for five hours to reach the hospital in Achham, I realized that medical textbooks had prepared me for diseases, but not for this reality. Rural Nepal doesn’t just test your clinical acumen- it tests your humanity. In fact, no doctor should miss the taste of medicine in rural life. But to make it viable, the state must introduce a well-rounded package- including rural allowances, fast-track academic opportunities and professional development credits.

The Missing Link

One glaring gap in our day to day practice troubles me- research and innovation. I, like many colleagues, see scores of patients each day and operate scores each week but rarely document cases for academic publication. This is partly because our medical education never truly cultivated a research culture. Hospitals and policymakers must encourage and support clinicians in producing case reports, studies and data-driven insights that can strengthen Nepal’s healthcare system. In addition, the mushrooming of medical colleges without strict regulation has also affected the quality, at times eroding empathy in doctor-patient relationships. Works like Dr. Nawaraj KC’s Shunyako Mulya, filled with poignant accounts from Karnali, remind us that compassion is as critical as any clinical skill.

From the rugged trails of Achham to the busy theatres of a provincial hospital, this decade has shown me both the resilience of our people and the cracks in our health system. The path forward demands not just more doctors in rural posts, but also fair incentives, stricter medical education standards, a revived culture of empathy and a commitment to research. Only then can we truly bridge the gap between the Nepal we have – and the Nepal we need.