A few days ago, I reached Tribhuvan International Airport on business. The airport was crowded. Someone called from the crowd. The man was a doctor. It could easily be guessed that he is going abroad because of the tattoo on his forehead and the food on his neck.

But two years ago, he told me that he would stay in Nepal and do something in the health sector here. He said - "Brother, I will not go abroad under any circumstances." I live in Nepal. I will work in the treatment of Nepali people.'

I remembered the same thing from him and thought, 'Have you received any honor or have you come to say goodbye to someone who is going abroad and given you vaccinations and food?' Why is that? Did you get respect or what?' He got a little emotional after my question. He remained silent for a few moments and said, "Brother, I could not stay in Nepal." I am going to America. I couldn't keep my promise to you in the past. Im sari dai.'

Determined to go abroad, he suddenly wanted to go abroad, so he sought to know the reason. He said, "This job does not support the family. Interest on loans taken while studying MBBS has also increased. Even while working, I was also afraid of who would come and attack me. Once, the patient insulted him without understanding. I am forced to go abroad brother.' 

His other friend who came with that brother is also preparing in America. He also complained that he was forced to go abroad. After talking with them, on my way back, I met another doctor who was working at Veer Hospital where I was working. He is also leaving Nepal and going to UK. Then I looked again at the crowd of foreigners at the airport. I walked out questioning myself how many doctors there would be in that crowd.  While exiting the

, I remembered the data of a study that I myself participated in a few months ago. In September 2024, a research article titled 'Migration of Nepalese Doctors: Trend Analysis and Policy Implications' was published in the Journal of Nepal Medical Association.

The study was done by four people including me. In which in 2023 only 2 thousand 582 doctors took 'Good Standard Certificate' to go abroad. The number was 2,189 in 2022 and 1,521 in 2021.

Similarly, in 2020, 1 thousand 87 people took the certificate. During four years, 7,360 people took certificates to go abroad. This statistic was very alarming. What is even more disturbing is that two of the four of us who participated in the study have already migrated to America. They are also forced to go to America due to lack of opportunities in Nepal.

The statistics shocked me because they are not only raising their voices for the rights and interests of doctors and for the development and expansion of Nepal's health services. Our study was not limited to finding the number of expatriates.

Why are Nepali doctors going abroad? And what if the number of foreigners can be reduced? The crux of the matter was to find out. After finding the cause, he said that he should not only give suggestions to the government for its solution, but also work for it himself. 

Due to doctor migration

Most Nepali doctors are forced to migrate abroad. Job dissatisfaction is the main reason doctors migrate abroad. The reasons for the lack of 'job satisfaction' among doctors are low pay scale, long duty hours, having to see many patients with little pay, lack of proper evaluation of work and other problems.

After studying MBBS, BDS or MD/MS level, what most doctors look for is a good job. He thinks that he will be able to meet the needs of himself and his family with that job, and that he will be able to pay off the loans he took while studying. Even those who have studied on scholarship are going abroad because they don't have jobs as they say, those who study by paying fees are being forced to go abroad to pay even more loans and support their families. 

One of the main reasons for not getting a job even after becoming a doctor in Nepal is the lack of increase in government posts. After 2048, the post of doctors has not increased. A doctor who wants to work in the government service has no way to enter a post without opening a new post. Since there is no permanent job, there is no job security for doctors in Nepal. 

There is not much opportunity in the private sector either. Even if a job opportunity opens up, there is no job security. If a doctor who goes to work in a private hospital fails to meet the target of the hospital management, then the doctor's job may be lost. They are at risk of being fired at any time. Another thing is that private hospitals do not have good salary facilities regardless of whether they are medical officers or specialist doctors. On top of that, the burden of unnecessary targets given to doctors by some private hospitals became more of a problem. Due to the lack of service facilities in both the government and private sectors, many Nepali doctors have chosen foreign lands.

Another problem is that doctors in Nepal are overloaded with work. By the time a person becomes a doctor, they are already 'burnt out'. Studying MBBS is difficult. After completing his MBBS studies, he has to work continuously for 72 hours for an internship. He becomes a medical officer only after passing the examination of Nepal Medical Council after the internship. After that, preparing for the entrance exam to read MD again, you have to be able to get your name in the exam, it is difficult to get a seat. 

In many countries of the world, doing MD after doing MBBS does not charge any fees and the subsistence allowance is also good. But in Nepal, we have to protest and demand rights. Hospital services should be boycotted. Why would anyone prefer to live in Nepal when they have to do this for the services they can easily get? 

Even those who manage to study MD/MS must pass and retake the licensure exam. A doctor has to prove himself time and time again. Even after getting the license, the doctor has to work overload. Doctors who are tired of studying are assigned to overloaded work. According to the Labor Act, doctors are required to work a maximum of 48 hours a week. But in Nepal, they are forced to work more than that in low service facilities. Because of this, doctors are forced to go abroad because they have fixed working hours and good salary facilities.

You don't have to work abroad for more than 48 hours, if the doctor gets sick after working more than that time, the organization takes his responsibility. Gets overtime benefits. 

In Nepal, on the one hand, one has to work overload, on the other hand, if a patient dies during the treatment, the doctor has to be beaten. While writing this article, it has come to light that a relative of a patient attacked a doctor in the operating room of Veer Hospital. What doctor feels safe and motivated to work when he is attacked like this while on duty serving patients? 

Instead of giving encouragement and encouragement to doctors who work day and night to save patients to the best of their skills and efficiency, they are insulted and attacked and even made to pay compensation. There is a situation where unnecessary accusations are being made against the doctors and some private hospitals even if there is no fault of the doctor in order to protect the reputation of their hospital, they are sacking the doctor. This is another reason why doctors do not want to stay in Nepal. 

Many doctors have left due to lack of professional security. After a doctor comes into practice, proving himself step by step, he is again tested by the crowd. insults. No doctor wants the death of the patient he treats. The doctor tries his best to save the patient. But in Nepal, doctors are tried to be made guilty by force. 

The study conducted by the International Labor Organization on the reasons for the migration of Nepali doctors and health workers also highlighted these issues. The study showed that Nepali doctors and health workers are migrating abroad due to good environment for working abroad, easy employment, good salary facilities, good lifestyle and living environment, good system of training at work, quality education, political instability in Nepal, easy visa for health workers abroad. How to stop

?

In the era of globalization, the migration of doctors abroad cannot be completely stopped, but if some steps are taken, it can be reduced to a large extent. When I was the president of the Nepal Medical Association, an amendment was made to the Act on the Safety of Health Workers and Health Institutions with strict legal provisions to reduce the incidence of attacks on health workers and health institutions.

Now the Act should be fully implemented. If the law is not implemented, it is not possible for doctors who are assigned to treat patients in sensitive places like health institutions and hospitals to feel safe and see patients. Even if the state were to fully implement the law, many doctors would be deterred from going abroad. A doctor can give good treatment only when the state's health infrastructure, buildings, equipment, technology are good. 

Let's say a good surgeon was transferred and reached a hospital in Bhojpur district, but there is no good operation theater, no anesthesiologist, no equipment and technology, then treatment of the patient at the right time is not possible only with the efficiency of the doctor. If there is no technology, equipment, the patient cannot be saved.

Only the doctor gets the blame. A doctor is not a skilled person who works in a team. Where the state's health infrastructure is weak, doctors are blamed and beaten up because patients could not be treated. The problem is that the state is not able to provide the things that the state should look after and the services that are needed. If the state does less in this matter, many problems will be solved.

The state can attract doctors in the country by giving concessions on other facilities. Just like Bhutan has a free ambulance system for patients, similarly there is a corresponding transport facility for doctors to reach the hospital on time for the treatment of that patient.

The government of Bhutan has given a tax break to doctors when they buy a car. This facility has been given to the doctor so that the doctor can reach the hospital on time and the patient can be treated on time. In Nepal, it is necessary for doctors to get a tax exemption on the purchase of a car. It is not that tax exemption should be given on very expensive cars, but a tax exemption can be given on a car for a basic need ranging from this amount to this amount. Doctors were given concessions on house loans, concessions on the education of doctors' children, and the doctors were satisfied and preferred to work in Nepal.

Nepal also has a civil hospital for civil servants, Army, Nepal Police has its own hospital. Civilians, Army, Police and their families get treatment there at ease and concessions. If the doctor gets sick here, he has to pay for treatment from his own pocket even in the hospital where he works. If a doctor also gets a serious illness, doctors have to raise donations and appeal for help. In this regard, the government needs to take necessary steps. 

Another problem lies in the taxes paid by doctors. Various taxes have been fixed according to the income of one percent of people earning up to 6 lakhs and above. Post-Covid, other countries have changed their tax policies for doctors. We also lobbied with the Ministry of Finance several times. But the Ministry of Finance has been saying that it will work, but not doing it.

A physician works full-time in an institution. There, the organization pays the salary after deducting the tax to be paid according to the salary facility. But apart from that when the same doctor goes to practice privately. When practicing in private, every penny is added to the total income and 36 percent tax is deducted. The tax policy itself is a problem because it is complicated. A doctor who earns 100,000 a month has to pay 40,000 as tax, what is his income?

Physicians who are working in a hospital should also be promoted to study research and training. It also attracts doctors to the country. Another thing is that there are problems in the hospitals in the city, while in the villages there is a problem of lack of doctors. In this too, the weakness of the state has caused problems. Earlier, those living in Kathmandu earned 40,000, while those serving outside Kathmandu earned 100,000. But now the facility of granting remote allowances has been removed. This has also discouraged doctors from serving in remote areas. The doctor wants to go abroad instead. 

Nepal has a population of 10 million and now the situation of manpower vacancies is the same. Veer Hospital had 500 beds before, but now it has 900 beds. A doctor who saw 1,000 patients in OPD yesterday does not even bother to look at the patient's face when he has to see 3,000 patients today. The doctor is only obliged to prescribe medicine. When you start talking well, all the patients who have arrived at the hospital are not afraid to see you. 

2 days off a week in the US has seen the effectiveness of work. Our Patan hospital also has two days off in a week. That is why the quality of service is good in Patan. Those who work in health institutions are treated as if they are not human beings. No holidays even on public holidays.

If the doctor takes a "forced leave" or gives a "vacation", he gets to spend time with his family without stress. Returning from leave also has a positive effect on their work. On the one hand, health is a sensitive area, there is a tradition that doctors should not be given leave and service facilities and salaries are not treated in a special way.

Until now, government hospitals have been run by salaried, contract, scholarship doctors only. It was only temporary manpower. After the federalization, the opportunity of people working at the local level to come to the center has been closed. There is a need to change the health policy itself. 

Health Act is about to come now that health is a separate sector. All health workers and doctors should be given special facilities under the Health Act. Even if a separate provision is made regarding the salaries and facilities of doctors and health workers in a separate health act, some of the problems seen now will be solved. 

Medical officers in Maldives have better salary facilities than in Nepal. Now medical officers go to Maldives and earn money and then come to Nepal to do MD. Earlier, only America, UK, Australia went. Now doctors have also started going to Dubai, Maldives for employment.