Human resources for health (HRH) is a fundamental component of the health system. A skilled and well-distributed workforce is essential for delivering quality healthcare and achieving Universal Health Coverage (UHC). HRH has been a critical topic of discussion in Nepal, particularly following the country’s transition to a federal governance structure. Despite this, Nepal’s legal framework for managing the health workforce remains outdated. The Nepal Health Service Act, 2053 (1997), which laid the foundation for workforce governance, has yet to be revised to address the complexities presented by federalism and evolving health system demands.

Missed opportunity

Nepal’s transition to a federal system, while offering potential benefits, has also created significant challenges for health workforce management. The country failed to utilise the transitional period following federalism to mainstream the Health Service Act within the framework of the national Civil Service Act or to integrate health worker mobilisation policies across federal, provincial and local levels. Even as the amendment to integrate health services within the Civil Service Act is already in place, it does not impact the overall health system since only federal health workers are managed under it.

Moreover, the Staff Adjustment Act, intended to facilitate employee transitions, has disrupted the traditional health worker’s chain of command and the “one-door” mechanism for HRH governance. This has led to administrative inefficiencies and unclear responsibilities for workforce deployment, upgrading, professional development and long-term management. Consequently, HRH management has become increasingly fragmented and ineffective.

Particularly troubling is the ad hoc policymaking by provincial and local governments, which have independently developed their own HRH mobilisation policies and undertaken cadre upgrades without standardised, scientific criteria. This approach has led to disparities in qualifications and competencies among health workers, undermining workforce planning and compromising service quality.

International migration and shortage

Challenges are even more acute in rural and remote areas, where access to professional healthcare services is already limited. Retention of health workers in these regions remains a major issue, compounded by the increasing migration of health professionals abroad. The resulting shortage has made it difficult to meet the healthcare needs of the population.

The Medical Education Commission estimates that Nepal currently faces a shortage of around 56,000 health workers. According to the National HRH Strategy 2030, the active health workforce must increase to 166,000 by 2030 to meet the World Health Organisation’s recommended density of 4.45 health workers per 1,000 population. This target is nearly three times the number of active professionals available in 2020. These figures highlight the urgency for a strategic workforce development approach in Nepal.

Brain drain among doctors, nurses and paramedics also remain a major concern. Data from professional councils show that approximately 9,500 nurses and 2,500 medical doctors received clearance for foreign employment, study or training in 2023. Poor working conditions, limited career growth, low attraction to government jobs, no retention policy and inadequate incentives are driving this exodus.

In this context, an integrated and comprehensive HRH mobilisation policy is urgently needed to ensure equitable workforce distribution, job attraction, retention, training and continuous professional development across all government levels. Empowering and strategically mobilising health workers can help fill service gaps and mitigate the effects of migration, especially in underserved areas. Such a policy must be well-aligned with the federal governance structure, facilitating effective coordination between the federal, provincial and local governments. Strengthening HRH information systems for workforce mapping, deployment and training will also be key to evidence-based decision-making and policy implementation.

Strategic policy solutions must address not only the quantitative shortages of health workers but also improve the quality and sustainability of the system. Nepal must explore innovative models for workforce retention, such as performance-based incentives, rural service allowances, workload-based position creation and career advancement pathways for in-service paramedics and other health professionals. HRH and health financing

Currently, the government of Nepal is investing lots of resources in medical education, particularly in fields like clinical doctors, graduate and postgraduate health courses, by offering full scholarships. However, many scholarship recipients seek international opportunities after completing their contract periods, leading to investment loss. Limited focus on training mid-level healthcare providers in a government scholarship has resulted in a low return on investment and poor value for money within the health system. Investing in government jobholder grassroots healthcare providers by offering training programmes, MBBS scholarships for health assistants and career development pathways would be a more sustainable approach to address the future health workforce shortfall, particularly in rural and remote areas.

Similarly, to strengthen and expand the impact of Female Community Health Volunteers (FCHVs), it is crucial to upgrade the existing selection criteria and prioritise locally trained Auxiliary Nurse Midwife (ANM) as FCHVs because this course is particularly designed to train a local fit-for-purpose health workforce in Nepal. Deploying certified ANMs as FCHVs will assure a higher level of healthcare expertise in communities. This approach would not only enhance Nepal’s community health services but also help address the crisis of health workers due to migration.

To further enhance the effectiveness of community-based healthcare, it is essential to revise recruitment criteria and mobilisation policy along with an attractive remuneration and benefits package for FCHVs involved in health service delivery at the local level. One important step is the phase-wise replacement of old FCHVs with trained women who have completed ANM training. It is also wise to provide some scholarship seats to existing FCHVs interested in pursuing ANM courses.

‘One Municipality, one Public Health Officer’

The Ministry of Health and Population has launched the much-awaited “One Municipality, One Public Health Officer” programme to strengthen local health governance. The initiative places graduate public health professionals in local governments to improve service delivery, support evidence-based decisions and enhance local health policy implementation. If implemented with federal oversight, the programme embeds qualified public health officers in municipalities and fosters collaboration between federal, provincial and local governments.

This initiative offers a valuable opportunity for all levels of government to demonstrate their commitment to coordinated HR mobilisation and evidence-driven and equitable health service delivery. However, the current contractual arrangement for these positions is temporary, whereas the programme requires permanent positions to sustain technical capacity and coordination at the local level. Embedding it in long-term policy and budget frameworks will help build a decentralised, robust and sustainable health system in Nepal.

Despite several challenges in health workforce management in Nepal, there are several opportunities to integrate and mainstream health workforce regulation to bridge the gap on mismanagement and shift priority towards establishing strong linkages across all tiers of government, aiming to unite fragmented health systems and build a more equitable, coordinated and community-driven primary healthcare framework. Continuing the ‘One Municipality, One Public Health Officer’ as a permanent position would be a strategic move by the Government of Nepal to integrate fragmented health systems and mainstream public health interventions nationwide. The targeted policies must be designed to enhance the capacity-building, motivation, retention and academic advancement of health professionals and community health volunteers.