A staff support programme for rural hospitals in Nepal

Abstract Problem District hospitals in Nepal struggle to provide essential services such as caesarean sections. Approach Retention of health workers is critical to the delivery of long-term, quality health-care services. To promote retention and enhance performance in rural public hospitals, the Government of Nepal and the Nick Simons Institute progressively implemented a rural staff support programme in remote hospitals. After competitive selection for a compulsory-service scholarship and training, family practice doctors who could do basic surgery, orthopaedics and obstetrics were hired under a binding three-year contract in each participating hospital. Comfortable living quarters and an Internet connection were provided for the resident doctors; in-service training for all staff and capacity development for each hospital’s management committee were provided. Local setting Nepal’s mountainous landscape, poverty and inequitable rural/urban distribution of health workers pose barriers to adequate health care. Relevant changes Between 2011 and 2015 family practice doctors were maintained in all seven programme hospitals. All hospitals became providers of comprehensive emergency obstetric care and served more patients. Compared with hospitals not within the programme, deliveries increased significantly (203% versus 71% increase, respectively; P = 0.002). The programme recently expanded to 14 hospitals. Lessons learnt A package of human resource supports can improve the retention of doctors and the use of remote hospitals. Factors contributing to the success of this programme were compulsory-service scholarship, central personnel management, performance-based incentives and the provision of comfortable living quarters.


Introduction
In remote areas, an absence of doctors and nurses leads to poor health outcomes for local populations. 1 To increase access to health-care workers, the World Health Organization recommends interventions in four areas -education, regulatory, financial and professional/personal. 1 To support retention, WHO and other organizations have called for bundled programmes that take into account health workers' expectations. [2][3][4] Retention programmes that enhance workers' competence, responsiveness and productivity have also been recommended. 5 Studies on retention of health-care workers in low-or middle-income countries tend to focus on compulsory government service 6 or on salary incentives. 7,8 Few studies have reported on bundled programmes or used patient volumes as outcome variables for such programmes. 3,6,8 Here we describe a bundled programme for human resource support in Nepal.

Local setting
In Nepal, the mountainous landscape, poverty (the annual gross domestic product per capita is 300 United States dollars, US$) and an inequitable rural/urban distribution of health workers pose barriers to adequate health care. 9, 10 Eighty-three percent of 28 million Nepalese live in rural areas. These areas are served by 15-bed public district hospitals, 11 which are expected by the Nepalese Government to provide emergency operations. However, in 2006, only 10 of 64 (16%) district hospitals were able to perform caesarean sections, due to absent, low-performing or mismatched healthcare workers. 12 The support programme To address low retention of health-care workers and poor performance in district hospitals, the Nepalese Government partnered in 2006 with the Nick Simons Institute -a nongovernmental organization working to improve health care in rural areas by supporting Nepalese health-care workers. The partnership developed a rural staff support programme, based on international consensus about retention factors, 1,3 experience in the Nepalese health-care system 13 and stakeholder consultations.
The central component of the rural staff support programme was recruiting one or two family practice doctors per programme hospital. These physicians are post-graduate doctors trained in medical universities in Nepal -to provide primary care as well as basic surgery, orthopaedics and obstetrics. To recruit these doctors, we first negotiated with the medical university for three to six seats per year in the post-graduate family practice programme. Then we advertised in newspapers for junior doctors with at least two years of working experience and who had either been raised in or who had previously worked in rural areas. We chose 15 to 20 applicants to take an entry exam. Three to six applicants with the best results were offered a scholarship for the three-year post-graduate programme and binding contracts for a subsequent three years of service in a programme hospital. Doctors who chose to leave the programme early incurred a financial penalty twice the scholarship, which varied from US$ 20 000 Problem District hospitals in Nepal struggle to provide essential services such as caesarean sections. Approach Retention of health workers is critical to the delivery of long-term, quality health-care services. To promote retention and enhance performance in rural public hospitals, the Government of Nepal and the Nick Simons Institute progressively implemented a rural staff support programme in remote hospitals. After competitive selection for a compulsory-service scholarship and training, family practice doctors who could do basic surgery, orthopaedics and obstetrics were hired under a binding three-year contract in each participating hospital. Comfortable living quarters and an Internet connection were provided for the resident doctors; in-service training for all staff and capacity development for each hospital's management committee were provided. Local setting Nepal's mountainous landscape, poverty and inequitable rural/urban distribution of health workers pose barriers to adequate health care. Relevant changes Between 2011 and 2015 family practice doctors were maintained in all seven programme hospitals. All hospitals became providers of comprehensive emergency obstetric care and served more patients. Compared with hospitals not within the programme, deliveries increased significantly (203% versus 71% increase, respectively; P = 0.002). The programme recently expanded to 14 hospitals. Lessons learnt A package of human resource supports can improve the retention of doctors and the use of remote hospitals. Factors contributing to the success of this programme were compulsory-service scholarship, central personnel management, performance-based incentives and the provision of comfortable living quarters.
Lessons from the field Rural hospital support programme in Nepal Mark Zimmerman et al.
-30 000. Once posted in the programme hospital, the doctors received salaries three times higher than the usual basal government rate, not including other government benefits. To facilitate an effective hospital team, the programme also provided personal, professional and management support for all staff working in the hospital ( Table 1). The programme was implemented stepwise: In 2007, three hospitals started the programme and in 2009, they were fully operational when scholarship doctors began to graduate from their training programmes. In 2011, four more hospitals joined the programme. All seven hospitals (Bajhang, Kalikot, Doti, Salyan, Kapilvastu, Gulmi and Dolakha) were rural, some were in extremely mountainous regions, and all their districts were below the national Human Development Index mean of 0.471. 14 In 2008, we hired one centrallylocated nurse coordinator for the programme team. This nurse administered the programme and provided counsel-ling to doctors and nurses posted in the remote hospitals. She shared success stories with other hospitals, the government, the local newspaper and published these in the institute's annual reports. When the programme grew to seven hospitals, we hired a second nurse coordinator.
In 2010, we did a detailed evaluation. Hospital staff mostly appreciated the Internet access, hospital equipment stipends and renovations of staff quarters. However, two components did not produce the expected outcomes. The children's education component assisted certain schools, yet many staff chose to send their children to other schools. Efforts to connect these small rural hospitals with a larger hospital failed because staff in the larger hospitals were too busy with their own work to develop useful support relationships with staff working in the programme hospitals. These two components were therefore replaced with two new components in 2011 -connection with district health posts and continuous quality improve-ment (Table 1). We also interviewed a small number of relatives of outpatients and inpatients to assess community satisfaction.
In 2011 we added a job description for the family practice doctors and a performance-based incentive, which was a lump sum of maximum 20% of the total salary. The lump sum depended on a doctor evaluation score. For example, if the doctor scored 80%, he or she got 80% of the maximum lump sum. In each hospital, we also introduced and monitored a self-administered quality improvement tool designed to address equipment and management gaps that affected patient care.
The institute bore all programme costs. The programme cost was US$ 66 387 per hospital per year -49.2% (US$ 32 667) for doctors' scholarships and salaries, 45.3% (US$ 30 073) for other programme activities and 5.5% (US$ 3651) for central management. This cost was approximately 50% more than a parallel, government scheme that provided emergency obstetric services

Programme outcomes
All doctors reported that they settled uneasily into their new workplaces: they felt isolated, both geographically from their homes and professionally from the medical hierarchy of their training hospitals. Nevertheless, the programme was able to continuously post at least one family practice doctor in each of the seven hospitals.
Five out of the programme's first 20 doctors chose to pay off their bond before fully completing their service period. As of 2013, three of these five doctors continued to work in rural hospitals for other organizations.
All seven programme hospitals became providers of emergency obstetric care and doctors did between 10 and 50 caesarean sections per year in each hospital.
We used changes in hospital use as a proxy indicator for community satisfaction and quality of care. We collected data on numbers of outpatient visits, admissions, deliveries and caesarean sections. Comparing patient use before (2006)(2007) and after (2012)(2013) implementing the programme, all programme hospitals showed increases in all four indicators. Mean annual admissions and outpatient visits per hospital almost doubled, from 832 to 1592, and from 10 585 to 21 341, respectively. Mean deliveries per hospital per year tripled, from 152 to 462. The mean annual increase in caesarean sections was 23.4 per year; from 1.4 to 24.8.
We compared use data between programme hospitals and district hos-pitals not within the programme. The 34 control hospitals with complete data also showed increased use between 2006 and 2013. Mean annual admissions, outpatient visits and deliveries per hospital increased approximately 1.5 times, from 1231 to 1770, from 13 065 to 19 299, and from 298 to 511, respectively. The mean annual increase in caesarean sections increased from 2.1 to 24.5. When compared to the control hospitals -using a non-parametric rank test -programme hospitals had greater improvements in the number of deliveries (P = 0.002) and caesarean sections (P = 0.056). Admissions (P = 0.151), and outpatient visits were not significantly increased (P = 0.544; Fig. 1).
In the evaluation and during regular hospital visits, staff strongly requested that the programme be continued in their hospital. Though staff other than doctors appreciated the programme, they complained that they were not being compensated for having to treat more patients.

Lessons learnt
To improve performance in poorly functioning rural public hospitals, we created a staff placement and support programme based on three principles -personalized management, bundled support and programme evaluation and revision. We recruited and deployed family practice specialists who were capable of providing a range of services. We added several comfort and professional supports to a bundle that we revised after evaluation to improve the programme. The use of and types of surgical services available in the programme hospitals increased (Box 1). Compared with control hospitals, all programme hospitals showed a higher increase in deliveries; all hospitals were converted into continuous providers of emergency obstetrics services; and the changes in hospital services all met with community satisfaction. While a parallel government-contracted doctor programme provided discontinuous service, 15 the rural staff support programme maintained a continuous supply of family practice doctors to each hospital.
The main challenge of the programme was to motivate -and ensure effective collaboration between -family practice doctors and their government medical superintendents. We had to overcome the preconceptions that rural hospitals had always been, and would likely remain, dysfunctional. This challenge was addressed by the programme's long-term commitment and its responsiveness to each hospital's unique situation. Another challenge was the medical superintendents themselves, who varied widely in both their desire to upgrade their own hospitals and their management capacity. We addressed this challenge by giving them control over the equipment and training budgets and giving them credit for the programme gains.
In 2013, during the sixth year of the programme, the Nepalese government asked that the programme be expanded to 25 more district hospitals. However, limited numbers of scholarship doctors meant that only four hospitals in 2013 and three in 2015 could join the programme, resulting in a total of 14 functioning programme hospitals. The programme plans to expand to 18 hospitals. In 2015, the Nepalese health ministry, using its own budget, instituted a similar programme to recruit, bond and deploy 40 family practice doctors per year in public hospitals.
A compulsory-service scholarship programme for doctors that includes staff and living supports could be a viable model in other countries that face problems in delivering health-care services in remote areas. ■