Nepal by Mary Martin A. Introduction to the country and region Nepal is a small, landlocked country of South Asia, and lies in the shadow of the Himalayas, the highest peak of which is Mount Everest. Nepal is roughly rectangular in shape, covering an area of 147,181 sq. kms and sandwiched between two big Asian giants, China in the North and India in the South. Nepal is ranked as one of the poorest countries in the world with a per-capita GNP of US$ 260, and ranked 136/177 on the human development index.
Various studies conducted in the past gave different statistics on the prevalence of disability in Nepal. The sample survey of disabled person in Nepal conducted in 1983 showed that 3% of the total population were disabled. A situation analysis on disability in Nepal conducted by UNICEF in 2000 found 1.63 % of the total population were severely disabled which is quite a contrast to WHO's estimate of 10% of the total population as disabled in developing countries. A recent survey on disability in Nepal is the 'District Disabled Survey - 2005', conducted jointly by the Local Government and World Vision Nepal in Sunsari District in Eastern Nepal. The survey revealed that out of a total population of 640,295, 31,160 people were found to be disabled. This is 4.87% of the population, which is close to the national estimates of about 5% made by NGOs working with disabled persons. Of course all these surveys use slightly different definitions of disability, so it is difficult to compare the statistics.
Disability in Nepal is a major issue, yet it has not been a high priority for service providers or policy makers. There is not adequate service provision to ensure that disabled people, particularly children, are able to grow like others and take advantage of the rights and opportunities offered to other citizens. If we were to refer to national estimates, such neglect would affect 5% of the country's population, which means that about 1.1 million people would be neglected.
Mary Martin teaching physiotherapy students at Dhulikhel Medical Institute
[1] Nepal Demographic and Health Survey, (NDHS) 2001. FHD/DHS/ORC Macro and New Era (USAID funded).
C. Health Care System Nepal’s government funded health care system is very poor, with most people having little or no access to adequate health care. There is a system of health facilities, starting with sub health posts in many villages to health posts (one might have to walk up to 8 hours to get to a health post – there are often no roads), primary health centres (which would have a few beds), regional hospitals, and then zonal hospitals (there are 5 zones in the country). The set up appears to be well thought out, however most health posts are staffed only by an untrained person; who holds the key, but has no medical training. Many health posts have no medicines and no trained staff. Several hospitals have no doctors. People often have to walk for several days to reach a hospital, carrying the sick person on their back in a basket supported by a tump line across the porter’s forehead.
Once a hospital is reached, poor patients can sometimes get free care, although all medicines must still be paid for by the patient. Before surgery the patient’s relatives must supply the needed blood, IV tubing, plaster, canula, or whatever else will be needed. The ratio of doctors to population is somewhat deceiving, as most doctors prefer to live in Kathmandu, the capital city, and refuse to work in rural areas. Thus Kathmandu is overstaffed with doctors while other places have no doctors.
Private hospitals are increasing in number, though usually only in Kathmandu or a few other large cities, and only for the rich who can afford to pay the very high prices. These hospitals are often well staffed, and surgeons and other skilled staff are competent. However hygiene standards are poor and infections are frequent. D. Disability and Rehabilitation A huge challenge we face in Nepal is access to quality physiotherapy service
Cost is an issue for most patients
Location and difficulty of travel is another huge issue. Most physiotherapists want to live and work in the larger urban centres and so rural areas are very under serviced. This is true of all health care services. I treated an amputee – a 14 year old boy who had been bitten by a snake near his home. His father carried him for 8 days, to the nearest road, and then took a bus for 24 hours to reach the hospital, by which time the leg could not be saved.
Knowledge about physiotherapy
By doctors
By patients and family
Knowledge about cause of disability
“Fate/superstition/the gods” are the three most common answers to the question “what is the cause of your disability?”
Another big issue and challenge is dependency
There is a substantial education gap between the physiotherapist and the average patient. This means that fancy treatment, like many forms of electrotherapy, can seem like magic to the patient.
Often patients then:
Want more magic
Know that they cannot do it themselves
Go to huge financial hardship to continue
Lack of education can also mean that the patient and family have difficulty understanding the nature of their problem or the nature and relevance of the treatment
A culture in which families want to help, to do for the patient. True in Canada too, but it seems to be more so in Nepal.
Sometimes financial greed on the part of the physiotherapist can encourage repeated visits when teaching the patient might have made them more independent of physiotherapy
So dependency is a big challenge. In our physiotherapy department in Canada I once put up a quote “If I treat you, I can help you today. If I teach you, I can help you for a lifetime.”
Staffing is another big challenge in Nepal
There are fewer than 100 qualified (diploma or degree) physios in the whole country, to serve a population of 26 million
The government will not/cannot create more physiotherapy posts (only 3 new posts have been created in the past 10+ years). This is likely due to the:
Lack of understanding of the benefits of physiotherapy
Lack of a powerful lobby – by patients, by doctors, by government
Lack of money
The private sector will eventually saturate, and serve mainly the rich
The preferred location of physiotherapists, (not rural)
When I was working to get Physiotherapy training restarted, I was asked by the Ministry of Health:
“If we start physiotherapy training in Nepal, will there be jobs when these physiotherapists graduate?” Yet hospitals will not create posts because there are no physiotherapists to fill them…
In order to address some of these issues, Nepali physiotherapists must:
Build awareness of the benefits of physiotherapy, the vital role physiotherapy can play in many conditions and situations
Advocate for the right of each person with a disability or injury to have access to quality rehabilitation, by a qualified and competent physiotherapist
Monitor our own profession, ensure that our graduates are competent and ethical, and if they are not, we must have mechanisms to deal with that
We must ensure that the public is protected by having laws which ensure that every person who calls themselves a physiotherapist is indeed a fully qualified and trained professional
We must link with other related professionals, not being protective of our own turf, but looking to the needs of the patient. In particular I think as long as we are unable to supply the rural areas with qualified physiotherapists, we need to be doing everything possible to support community based rehabilitation field workers, to train and support them, to teach them who to refer and when and where. If they are the only rehabilitation most rural people will ever receive, let’s make that rehabilitation the best it can be. Let’s cooperate with, and support CBR workers.
Status and History of the Physiotherapy profession in Nepal o There are less than 100 qualified physiotherapists in Nepal o There is one training course (3 year, diploma, at Kathmandu University), which graduated its first graduates in November 2005 (10 graduates). There had been formal (university, diploma level) training in physiotherapy in 1983-1990, after which it was stopped. o Physiotherapists must be licensed by the Nepal Health Professional Council, but this is not enforced o There are many people working as “physiotherapists” who are only on the job trained. Competencies of these people vary tremendously. o Anyone may call themselves a Physiotherapist; there is no legal protection of title. E. Personal Experience I lived in Nepal from 1983-1987, when I taught at the university in the first physiotherapy training course. I returned to Nepal in January 2000, and have continued to live here since. During this time I have been working with the United Mission to Nepal (UMN), a Christian development agency which has been in the country for over 50 years. Originally my job description read to "help the Nepalis better help their disabled", but over the years my work has taken many forms. I was responsible for restarting physiotherapy training in Nepal and am now the course coordinator in charge of the physiotherapy certificate programme. This 3 year diploma course is run at Dhulikhel Medical Institute, part of Kathmandu University. My role is to oversee and coordinate the work, and I do very little direct teaching. At present we have 3 expatriate teachers and two Nepali teachers. We are hoping and trying to move to having Nepali teachers do most of the teaching. Our first batch of graduates completed training in November of 2005. I am also an advisor to the Nepal Physiotherapy Association (NEPTA), and am encouraged by their growing professionalism. As physiotherapy is still in its infancy in Nepal, everything is challenging. We have now adopted a code of ethics, but standards of practice are still a distant dream.
The United Mission to Nepal has a disability programme, in which we try to work with various Nepali partners to improve the situation of disabled in Nepal. We have a Nepali Physiotherapist who heads up that work. We would like to have an Expatriate advisor to work with him in this work.
My work has now moved into more of an administrative focus, and I am responsible for overseeing our work in such diverse areas as food security, enterprise development, HIV/AIDS, children at risk, advocacy, peace and conflict transformation. It is a totally new type of work for me, and I am finding it very challenging and growing.
As an expatriate working with the United Mission to Nepal, I am supported by friends in Canada and other countries, both for financial and prayer support. All the expatriates with UMN are practicing Christians who are supported financially by churches and friends in their home countries. UMN has people from about 20 countries, who usually come to Nepal for terms of 3 or more years Physiotherapy successes have included: o NEPTA became a member of WCPT in 2003, and I carried in the flag representing Nepal. Unfortunately, no Nepali could afford of attend. o A batch of 10 graduates with more on the way. o The physiotherapy students I taught in the 1980’s are still working as physiotherapists here in Nepal, and form the core of the profession. We have also face the following challenges: o The hesitancy of Nepalis in authority to make any decisions. I worked for 1 ½ years before I got a “no” from the first university I approached to run the physiotherapy course. · The role of fate and fatalism in Nepali culture makes a rehabilitation approach very foreign to most Nepalis. F. Recommendations There are few opportunities for physiotherapists to come and work clinically in Nepal. A working visa is extremely hard to obtain, and it is illegal to work on a tourist visa. Tourist visas are only issued for a maximum of 5 months in any calendar year.
There are now Nepali Physiotherapists working in many hospitals and doing a good job. The need for expatriate teachers to work in the physiotherapy school will hopefully be decreasing as we get more Nepalis doing the teaching. Some of the hospitals listed below do take on short term volunteers, who pay their own transportation and usually do not receive any salary, rent or food allowance.
References and related websites: Nepal Physiotherapy Association: United Mission to Nepal: www.umn.org.np Spinal Injury Rehabilitation Centre: .np Hospital and Rehabilitation Centre for Disabled Children: .np Handicap International: Sushma Koirala Memorial Hospital:
Contact Information Mary Martin
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