There are over 100 institutes producing trained nurses in the country. And, 3000 nurses graduate each year. Yet, when you go to a hospital, you don't get efficient service because there are far fewer nurses than what the service demands. Reason: this country has long been gripped with the brain drain, and solution seems nowhere in the sight, as nurses keep on going abroad in search of greener pastures and the government is not doing anything to retain them. A case in point: a nurse, Mandira Poudel, 26, says many of her friends have already landed in the West. "Among the rest, there's hardly anyone who's not trying to go," says Poudel, who has been serving in the Koshi Zonal Hospital for the last three years, adding that the United States is her ultimate destination. Another nurse, Niva Devkota, has a similar dream. But, Devkota says she will stay in Nepal only if there is better working environment and more pay. "Our job demands very hard work," says Tara Sunuwar, 27, a staff nurse at the Bir Hospital. "But we neither get good salary nor is there opportunity in Nepal," adds Sunuwar while nursing a patient in the general ward of the hospital. Though Sunuwar was denied visa to the United Kingdom once, she is going to tray again soon. "I will try my best go to the UK." As there are insufficient working nurses at the hospital, she often does overtime, which has affected her own health. According to data provided by the Nepal Nursing Council (NNC), there are 16,206 nurses -- including 8,190 ANMs (Auxiliary Nurse Midwives), currently employed in Nepal. However, this number fills only 45 to 50 percent of quotas of the nurses required in the health institutions. The trend of nurses going abroad, according to NNC, started about six years ago and the number of those going abroad has gone up sharply in the last two years. Though most of the nurses going abroad get a letter from the NNC, some don't, making it difficult to calculate the exact number. Nowadays, according to Ishwori Khanal, registrar of the NNC, five nurses on average come here to make the letter each day. Only old ladies may remain Nursing professionals fear that if the current trend of young and talented nurses going abroad is not checked, only old ladies may remain here in the not-so-long future. According to Ishwari Shrestha, the matron at the Bir Hospital, patient-nurse ratio at this biggest government hospital of Nepal is 20: 5. "That's why nurses show irritation and cannot give quality service," says Shrestha. For the total 489 beds in the hospital, there are only 189 working nurses.
"According to international standards," says she, "there should be one nurse per patient." "All young girls try to go abroad as their job here is very demanding and the pay is low. It seems only old ladies will be working as nurses here in the future," sighs Shrestha. The picture is no different at the Tribhuvan University Teaching Hospital (TUTH). Matron Jamuna Sayami, under whom 300 nurses are currently working, says that she has not been able to fill up the entire quota of nurses in the hospital despite all her efforts. "Almost all of the young nurses are in the process of going abroad," says Sayami. "And when they get a visa they fly away without any notice." 'Health sector needs policy revamp' Health professionals point out that a major policy revamp is needed in order to keep health institutions running smoothly. "We're still following the planning framed some 20 years ago," says Jamuna Sayami of TUTH. "While making strategies or policies the government should take every aspect of this sector into account." Shanta Rai, the vice-president of Nepal Nursing Association, says that the government has been apathetic to their demands for revamping the overall management of the nursing sector. "We've been demanding increased salary and quota for nurses in the government hospitals, but the standard excuse is budget constraints," she claims. Sayami says that critical cases are regularly increasing in hospitals, which means that Nepal needs extended human resources in the health sector. Let alone the inadequacy of nurses in rural areas, according to her, there's a big lack of sufficient number of nurses in the hospitals and nursing homes in the capital too. Spokesperson at the Health Ministry, Arjun Bahadur Singh, says that reforms in this sector are in the pipeline. The country, according to Singh, will soon witness a well studied plan and structures implemented. "We have already started programs to reform this sector."

Sri Lanka is not much different from Nepal in area and population. But Sri Lanka has a quota for 70,000 health workers, while Nepal with a much more difficult terrain, and lack transportation facility to many areas, has only 27,000 health workers - of which many posts remain vacant.
A case in point is Seti Zonal Hospital, operating without adequate human resources for the past several years.
The hospital which caters to 300 to 350 patients daily has only 10 doctors out of 19 as categorized by the government. Of the ten doctors one an intern. Similarly, the hospital doesn't have senior nurses, of which there is a quota for two. Though the government had deputed two senior nurses to the hospital some four months ago, they are yet to reach the hospital. All work supposed to be performed by them is being handled by the only matron of the hospital, while Dr. Ganesh Bahadur Singh, acting medical superintendent and one of two male gynecologists of the hospital, have to manage administrative work also. He hardly has time to provide medical services. "The patient load is increasing but we lack specialized staff," he said He said that along with shortage of necessary human resources, the government does not provide enough equipment also.
The lack of proper medical service has forced people in the region to go to Nepalgunj and India, confesses Dr Singh. Serving as a zonal hospital for 23 years now, the hospital is a referral hospital for nine districts of the mid and far western regions.
The National Review Meeting of health directors from five development regions held last month revealed that only 40 to 45 per cent doctor's quota and 45 to 50 percent of nurse's quota are filled in health institutions, while the rest remain vacant.
Of the total quota for health institutions, the Ministry of Health and Population has a quota of 1,200 doctors for eight national hospitals, two regional hospitals, nine zonal hospitals, 66 district hospitals and 210 Primary Health Centers. This quota was allocated some 28 years back during the fifth five-year national plan.
According to Dr Babu Ram Marasini, deputy health administrator of the ministry, some 25 percent doctors remain on study leave, due to which positions of some 300 doctors always remains vacant, while some five to 10 per cent go abroad or leave altogether.
Until 1992, the ministry had a reserve pool of 300 doctors, and the government used to transfer those going for study or abandoning their jobs to the pool and those from the pool used to be transferred to the vacant posts.
Of the total district hospitals, 14 are being run without senior doctor for the past four years, since the Supreme Court has not decided on the writ by Dr. Abdul Rahaman of Ramechap filed in 2002/03. Dr. Upendra Devkota, the then health minister had decided to promote doctors serving in 14 district hospitals that fall in remote geographical area. The process was stopped following the writ. District hospitals have a quota for two doctors only.
Similarly, the ministry had sought applications from doctors to serve as consultants for remote health institutions to ensure the continuation by doctors. But only seven doctors applied, that too after the vacancies were announced for the third time.
For them the ministry of finance had permitted Rs. 25,000 per month. "I am not sure that even those seven are working currently," said Dr. Marasini.
A study conducted jointly by the ministry of health and Fulbright Consultancy during June - July this year in 75 health institutions of the country, that included primary health centers, health posts, and sub-health posts shows that only 77 per cent of health workers are currently working, while 23 per cent remain absent. Health Posts and Sub Health Posts don't have quota for doctors, though. "The vacant posts are of technical ones," added Dr. Marasini.
Government doctors are paid about Rs. 10,000 without any additional facilities if they are serving in less remote areas, though they are paid 100 per cent remote allowance and Rs. 4,000 - 5,000 non-practicing allowance. Doctors are paid Rs. 13,000 to 20,000 by private hospitals, which mostly are urban centric.

"Your tempo's turn buddy. Would you like to have some mouth-watering pickle?" said Meena Magar, 26, from Hetauda on a recent afternoon in front of Nepal Airlines Corporation (NAC) building at New Road Gate.
"Won't you let me take a nap?" snapped Sumitra K.C, 28, who hails from Solukhumbu. Such candid conversation is routine for women who come from many regions of the country to operate tempos.
Eight years ago it would be major news if women were seen on the driving seats of the popular three wheelers, as driving tempos was thought to be an occupation for males only.
Now women have not only left the males behind by getting noted as safe drivers, but have also brought significant changes in their own and their families' lives through this job, which they seem to enjoy.
"We are satisfied with this work. This is quite an achievement for women like us from rural backgrounds," said Meena. "We are now able to speak frankly with anyone, anywhere. Otherwise, it was only males who could do so and we were supposed to speak within limits all the time."
Sumitra was quick to add, "Unlike before, we can respond quite fittingly when treated disparagingly by anyone."
Seeing Sumitra busy answering the Post's queries, women drivers gathered in front of NAC building one after another and were all eager to disclose with pride that the job has given them money, identity, and freedom from male domination not only during their working hours, but also at home.
"My husband takes care of household chores as I'm busy driving a tempo from seven in the morning to seven in the evening," said Sabina Lama, 27, from Dhading.
Lama's husband and a school-going son both are happy about her job. "My son feels good about my job, despite the fact that I'm just a driver. My son is a boarder at Gillette Boarding School and this was possible because I earn around fifteen thousand rupees monthly," said the proud mother.
It's not only Sabina who is so lucky. Sumitra's husband supports her in a similar way.
"My man also supports me in household work," giggles Sumitra. "We shifted our daughter from a government to a boarding school after I took to driving five years ago."
"She's getting married soon," the ladies teased a 24-year-old woman who was listening keenly to the conversation. "I'll marry only when I own a tempo," Sushma Khatri shot back.
Owning a tempo is a big achievement for these drivers, because then they won't have to share their daily earnings with the tempo owners. And of course they feel more empowered when they are 'the boss' themselves!
Rupa Giri, who owns the temp she drives said, " My husband went to Malaysia and came back with around twenty thousand rupees after two years. On the other hand, I have been able to pay back the cost of my new tempo (Rs 450,000) within just two years by working in my own homeland."
Similarly, Sumitra K.C fulfilled her dream when she became the owner of a tempo last year. About eight women own the tempos they drive, according to Ajay Kumar Rai, central president of Nepal Transportation Labor Union. "Of the one thousand tempo drivers in the valley more than 300 are women."

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