Status and availability of physiotherapy in Nepal as reported from facilities and official registers

doi:10.21203/rs.3.rs-3768164/v1

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Research Article

Status and availability of physiotherapy in Nepal as reported from facilities and official registers

https://doi.org/10.21203/rs.3.rs-3768164/v1

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published 06 Mar, 2024

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Background

Physiotherapy is a growing profession in Nepal, but there are challenges in providing equitable access and availability to physiotherapy services, particularly in underserved areas. There have been several efforts to promote physiotherapy services, however there is still a need to develop and strengthen physiotherapy and its services. Updated information and proper planning for resource allocation are important for addressing these challenges.

Objective

This study aimed to explore the status and availability of physiotherapy in Province 3 of Nepal.

Method

Data was collected through a cross-sectional survey of health facilities in the province using stratified purposive sampling. The eligible facilities were selected from the list of Department of Health Services. The survey contained closed-ended questions addressing primarily physiotherapy services in the outpatient department, human resources, charging and record-keeping systems, and accessibility. Visits to governing institutions and reviews of register data and reports were performed to obtain national physiotherapy data.

Results

The survey included 25 urban and 4 rural facilities, including hospitals and rehabilitation centres; both public (37.9%) and non-public (62.1%). Most facilities (79.3%) employed physiotherapists with bachelor's degrees. On average, there were 29.55 physiotherapy outpatients and 14.17 inpatients per day. Patient records were mainly paper based, with most (69%) using the hospital main card for patient case documentation, while others (31%) had their own physiotherapy assessment card. The majority of referrals came from doctors in different departments. The most commonly offered services were musculoskeletal, neurological, and paediatric physiotherapy. The average charge for a single visit was 311 Nepalese rupees ≈ 2.33 US$, and daily basis charging was common. Accessibility for patients with disabilities was reported as partial by 79% of outpatient departments. Two centres did not have disability-friendly settings, and only one had a disability-friendly toilet.

Conclusion

Overall, the study highlights the significant variations in physiotherapy services and the need for proper planning. The finding emphasizes the need for a proper data registry to inform resource allocation, as well as the need for monitoring services and further research on physiotherapy provision, particularly in underserved areas.

delivery of health care

NCDs

chronic diseases

health workforce

health policy

health services

Nepal is facing a significant prevalence of non-communicable diseases, disabilities, physical injuries, health consequences of modern lifestyles and hard manual labour, highlighting the need for urgent attention to the prevention and management of these health issues (1–3). Physiotherapy, as a non-invasive and non-pharmaceutical health profession, plays a vital role in addressing these health challenges, by working across different settings (4, 5). However, the profession is relatively new in Nepal and not well understood. To further develop and strengthen its role, knowledge of its status and availability is essential.

Physiotherapists are crucial members of multidisciplinary rehabilitation teams and contribute to promoting healthy lifestyles and addressing musculoskeletal, neurological, cardiovascular, and integumentary conditions across the lifespan (6, 7). As the demand for rehabilitation services continues to rise in developing countries, the promotion and availability of physiotherapy services are becoming crucial (8). Rural and remote areas in lower middle-income countries are often underserved by the rehabilitation workforce (9), leading to limited availability of services. Workforce maldistribution, lack of incentives for therapists, and inadequate skills for providing equitable physiotherapy services exacerbate this situation (10). Patient referrals to physiotherapists (11), affordability, and availability also impact accessibility (12, 13).

Nepal, with a population of 29.2 million people, is classified as a lower middle-income country (14) where approximately two-thirds of the population resides in urban areas (3). The country is divided into seven provinces, each having its own healthcare system at the federal, provincial, and local levels (15). Health facilities are categorized into primary, secondary, and tertiary levels (16), with significant variations in service provision between urban and rural areas. The challenging topography, poor road conditions, and transportation issues contribute to inequitable access to healthcare outside urban regions (17). Nepal is also prone to natural disasters such as flooding, landslides, and earthquakes, emphasizing the urgent need to assess the availability of services in the country.

Nepal is committed to accelerating universal health coverage by providing basic health services free of charge and implementing social health protection schemes, particularly for poor and vulnerable populations (16, 18). While efforts are being made to promote physiotherapy services in public hospitals, the Nepal National Health Policy 2019 has also encouraged private and non-governmental organizations to establish physiotherapy services at the federal, state, and local levels (19). Private service provision is considered crucial in the field of physiotherapy (20, 21). Despite the increasing use of private facilities in Nepal (22), the limited availability of health insurance (16) leads to unaffordable out-of-pocket costs. The provision of sufficient infrastructure in terms of suitable premises, equipment, and documentation systems for patient records, is important for improving healthcare (23). These issues need urgent attention in the physiotherapy sector in Nepal.

Health profession-related activities are overseen by the Nepal Health Professional Council (NHPC), an autonomous government body responsible for registration and policy making (24). Registered physiotherapists, with a minimum of bachelor’s degree, are represented by the Nepal Physiotherapy Association (NEPTA) (25, 26). According to the World Physiotherapy Global report 2022, there is an average of 3.6 physiotherapists per 10,000 people worldwide and for the Asia Western Pacific region, this number is 1.5. In Nepal, the estimated number is only 0.8 (26) and the attrition of physiotherapists as highlighted in a recent study (27), is a major issue that impacts the overall profession and its future.

There have been, however, developments, strategies, and plans aimed at developing and improving physiotherapy and rehabilitation in Nepal, initiated by several stakeholders. The Department of Health Services (DOHS), one of the governing bodies under the Ministry of Health and Population (MOHP), is responsible for addressing the aforementioned issues (28). Its objectives include providing preventive, promotive, and curative health services, providing technical advice for health policies, developing and expanding health institutions, determining manpower requirements, encouraging participation from the private sector and international institutions, coordinating and controlling the quality of health services, and maintaining data and information on health services (28).

Despite these efforts, Nepal still faces challenges in implementation resulting in huge gaps between plans and actions in all sectors (29). It is thus essential to gain updated information about the number and geographic distribution of the workforce and physiotherapy availability to enable planning of current and future resource allocation. To address this issue, a preliminary province-level survey would be significant to map the situation in addition to exploring national registry data and reports. Therefore, this study aimed to explore the general status of physiotherapy and its availability in different health facilities in a province in Nepal. For this purpose, it is considered relevant to gain information in terms of services, human resources, charging and documentation systems in outpatient clinical services, accessibility, academia, law, strategy, and policy briefings.

Design and setting:

This cross-sectional study was conducted in the Bagmati region, province 3 of Nepal, which is the second most populated area (20.84%) in Nepal; encompasses diverse ethnicities, all geographical zones, and complete administrative divisions; and includes the capital city of Kathmandu (3). While the on-site survey at health facilities was limited to province 3, the data collected from official reports and registers was of national level.

Data acquisition

Survey data: A list of facilities was collated from the DOHS website (30) and publicly available online directories. The list included 1450 non-public and 1139 public health facilities and 13 medical colleges in Province 3. Potential facilities were contacted to confirm the availability of physiotherapy services. To be eligible for the survey, a health facility had to provide outpatient physiotherapy and have a physiotherapist or health provider on duty with at least one year of working experience. Of the 47 potential centres contacted, 29 facilities were included in the survey (Figure. 1). The survey consisted of closed-ended questions divided into two sections: 1) information on the health facility in general, and 2) physiotherapy-related data divided into three categories: a) physiotherapy services and human resources, b) charging and physiotherapy record-keeping system, and c) accessibility (Additional file). The survey questions were pilot tested at five different centres and adjusted based on feedback. Physiotherapists or other primary contacts were identified for field visits and information about the survey was provided through email and phone calls. The data was collected on site, and a reminder was sent prior to the visit. A research assistant was trained by the primary investigator (NS) and supervised closely to ensure high-quality data collection. The survey data were recorded using a tablet in the Kobo data toolkit (31, 32). Data specifically related to outpatient physiotherapy services were collected (Table 1).

Register and report data

Key public stakeholders and national professional organisations were selected to obtain relevant data on the status of physiotherapy in terms of the workforce, education, and policies. Key contacts were identified, and permission was obtained to acquire the available data. Statistics on the registered physiotherapists were obtained from the NHPC and NEPTA. Other data was retrieved through visits of the primary researcher (NS) to governing institutions such as MOHP, the Medical Education Commission (MEC), and the Leprosy Control & Disability Management Section (LCDMS) under DOHS. National and international data from reports, journals, documents, websites, and formal and informal records regarding the workforce and recent developments were also included.

Ethics and permissions

Ethical approval was obtained from the Nepal Health Research Council-Ethical Review Board (NHRC-ERB Protocol No. 455/19), the Institutional Review Committee of Kathmandu University School of Medical Sciences / Dhulikhel hospital (IRC-KUSMS 104/18), and the Norwegian Centre for Research Data (NSD 383963). Permission was obtained from all the facilities included in the survey. Written informed consent was obtained from each participant prior to enrolment. Survey responses were anonymous, i.e., without identification or keys that could connect the responses to the consent form. The survey did not contain personal identifiable data that could connect the participant to a district or health centre. The data was securely stored on the university server.

Data analysis

Descriptive data analysis was conducted using SPSS 29.

Survey data

Of of the 47 facilities contacted, 38 were in urban and 9 were in rural areas. Two rural districts, Sindhuli and Dhading with populations of 300,117 and 322,751 respectively, did not have operational physiotherapy services during the data collection period. Two other rural districts, Rasuwa and Ramechhap, with populations of 45,554 and 170,620 respectively (3), had only one centre each; one centre did not respond and the other was excluded due to unsafe road conditions. The final sample included 29 health facilities, 25 in urban areas (12 in metropolitan cities and 13 in sub-metropolitan areas of Kathmadu and Lalitpur) and 4 in rural areas of Dolakha. The facilities included hospitals (n = 21), rehabilitation centres (n = 8) and a mixture of public (37.9%) and non-public (62.1%) settings.

The distribution of the workforce varied regarding the type, size, and location of the facility, with one facility having 18 physiotherapists and most having 1–4 physiotherapists. Most facilities (n = 21) employed at least one physiotherapist with a master’s degree where the specialties differed centre wise (Table 1). Seven facilities had only a bachelor’s degree-level physiotherapist, one lacked a physiotherapist with a university degree and had only one staff member with 3–18 months of vocational training. The majority of the workforce had a bachelor’s degree (n = 67), followed by a master’s degree (n = 50).

Table 1 Facilities providing physiotherapy services
Services and human resources	n (%)
Type of physiotherapy services
Outpatient services only	29 (100)
Both outpatient and inpatient services	21 (72.4)
Type of physiotherapy intervention
Endurance training, resistance training, flexibility, balance, gait training and motor re-learning	29 (100)
Electrotherapy, manipulation and mobilisation, supervised training in clinics, consultation services	28 (96.6)
Home programs	22 (75.9)
Massage therapy	2 (6.9)
Other physiotherapy services: sports physiotherapy, functional training, kinesiology taping, hydrotherapy, school health program, NDT (neuro developmental treatment), sensory integration, oromotor training, functional training, dry needling and acupuncture.	5 (17.2)
Specialist with Master’s degree (NHPC categories)*	n (%) denotes number of facilities employing specialist
Musculoskeletal and sports	15 (51.7)
Neurological and psychosomatic disorders	8 (27.6)
Paediatrics	5 (17.2)
Cardio-pulmonary science	2 (6.9)
Health promotion and rehabilitation	0
Specialist other than NHPC category (CBR-3, Rehabilitation officer-2, sports-1)	6 (20.7)
*Denotes multiple choice options, therefore the percentage does not total to 100
NHPC: Nepal Health Professional Council
CBR: Community based rehabilitation

The types of physiotherapy services provided varied between facilities. Hospitals with outpatient and inpatient physiotherapy services offered greater variety and more specialities compared to smaller rehabilitation centers (Figure. 2). The most commonly offered physiotherapy services in the wards in larger facilities were musculoskeletal, neurological, and pediatric physiotherapy, with many facilities also offering physiotherapy services for other medical conditions. One centre exclusively provided geriatric services, while another centre, though having a physiotherapy outpatient department (OPD), primarily focussed on distributing orthotics and prosthetics due to resource constraints.

The average number of physiotherapy outpatients per day was 29.55 (range 3–80) and inpatients was 14.17 (range 2–30), which also varied depending on type, size, and location of the facility. The referrals came mainly from orthopaedic, neurology, and paediatrics departments. Some patients were self-referrals coming directly to outpatient clinics (Figure. 3).

The average charge for a first or single visit at a physiotherapy OPD was 311 Nepalese rupees (Nrs) ≈ 2.33 US$, but varied greatly among the included OPDs, ranging between 90 to 1000 Nrs for a single visit, while two centres reported providing free treatments (Figure. 4). Charges for follow-up treatments ranged from less than 100 to more than 500 Nrs. Most centres (27, 93.1%) reported charging on a daily basis. Other charging systems included package-based, modality-based, or treatment-based charging.

Patient records were mainly paper based, with most OPDs (20, 69%) using the hospital main card for patient case documentation, while others (9, 31%) had their own physiotherapy assessment card.

Accessibility for patients with disabilities was reported as partial by 79% of the OPDs, foremost with regard to wheelchairs, providing a ramp, elevator, or stretchers. Two centres reported not having any disability-friendly services, while only one centre reported having a disability-friendly toilet.

Register and report data:

Physiotherapy workforce details

The NHPC database provided information on the registrations and numbers of physiotherapy professionals categorised under different levels. A master of physiotherapy was registered under five different specialisations (Table 1). Year-wise estimated records of the number of physiotherapists in Nepal from 2018–2023 were obtained from a workforce survey (27), the World Health Organisation (WHO) (33), World Physiotherapy (25), DOHS (34), and NEPTA (26). According to the NEPTA, the estimated number of physiotherapists in Nepal has increased 63% from 1587 (WHO, 31) in 2018 to approximately 2500 in 2023, while DOHS reported only 1200 for 2022. The registered number of physiotherapists in the Nepal Health Workforce Projection Report 2022–2032 (35) was also published in August 2023. Updated verbal information from the NHPC record (December 2023) revealed 313 master’s and 2003 bachelor’s graduates (total n = 2316).

Practice and academia initiatives

Physiotherapy practise in Nepal began in 1972, and in 2003, a certificate-level program was launched (36). This program was upgraded to a bachelor’s level program in 2010 by Kathmandu University School of Medical Sciences (37). Two colleges under Kathmandu and Pokhara University offer full-time bachelor programs (38), with four more colleges recently added to the list providing a total of 150 seats under the affiliation of Kathmandu University (39). In the fall of 2022, the first master’s program in physiotherapy was accredited at Kathmandu University (40), which currently has an annual intake of five master’s graduates specialising in musculoskeletal physiotherapy.

Strategy, plans, and policies related to physiotherapy

Government databases, journals, and reports revealed significant work in progress. After the earthquake in 2015, the National Health Sector Strategy III, 2015–2020, referred to physiotherapy as part of Basic Health Services. The MOHP has included standards for physiotherapy under the minimum service standards for secondary and tertiary hospitals. The National Strategy for Reaching the Unreached 2016–2030 includes the establishment of physiotherapy units in hospitals (41, 42). According to the DOHS annual report 2020/21 (34), physiotherapy clinical protocols and standard operating procedures were developed. The report highlighted the strengthening of existing physiotherapy units and promotion of the establishment of new units in government hospitals (34). However, physiotherapy services are lacking in secondary hospitals and government primary care facilities (41).

This study provides the first comprehensive overview of physiotherapy service provision in Nepal, revealing significant geographical imbalances and varying levels of availability and distribution of physiotherapy. The study also highlights the need for accurate baseline data from registered physiotherapists. These findings have implications for resource allocation decisions and contribute to facilitating more logical physiotherapy allocation in all provinces. Our study sheds light on difficulties in health systems research in the Nepalese context, as ethical, financial, and logistic issues are the major ones.

Our study supports the notion that physiotherapy services are primarily concentrated in urban health settings, as reported in previous studies in other countries (10, 21). This finding corroborates previous report in which 71% of physiotherapists in Nepal were reported to be concentrated in province 3 (41). One previous study suggested that the distribution of physiotherapists can be related to population density and monetary resources, as well as other potential influencing factors such as the availability of public and private services, or professional opportunities in cities (43). However, the limited availability or lack of physiotherapy services in rural districts with significant population density, reported in our study could be due to a lack of prioritization, awareness about the services and low pay scale in such geographical areas (44).

Our results revealed a low frequency of physiotherapists particularly in cardio-pulmonary and paediatrics specialisations, although the availability of and referral for such physiotherapy services at the surveyed facilities were significant. This finding is consistent with the World Physiotherapy interview report that highlighted the key challenges faced by Nepali physiotherapists in recognizing specialty-based physiotherapy practices (44). This may also be reflected in a Canadian study that indicated physiotherapists generally assume a generalist role, providing different clinical services to their patients (45). Our study also revealed a physiotherapy unit operated by a non-qualified physiotherapist, indicating the need for proper implementation of hospital service monitoring and strengthening by concerned governing bodies such as the Bagmati Province Health Directorate (46), DOHS (47) and health sections at local governments. Such practice is also in defiance of World Physiotherapy and NHPC regulations where authorization as a registered physiotherapist requires a minimum bachelor's degree in physiotherapy for clinical practice (25).

Our study showed that access to physiotherapy heavily relies on doctor referrals from various departments. However, studies have suggested that direct access to physiotherapy via self-referral (48, 49) could contribute to increased availability and a reduced healthcare burden on doctors without significant risk to patients (50, 51). The present study also revealed inconsistent and varied charging systems in most of the physiotherapy facilities that could raise concerns about the quality of services. Our study also revealed that most Nepali physiotherapy facilities use hospital OPD cards for documentation. Only a few had their own physiotherapy evaluation forms, indicating a lack of systematic documentation. Our findings on the challenges associated with physical accessibility and disability-friendly design were consistent with findings of the Nepal health facility survey 2021, which showed that most health facilities lacked accessible doors, entrances, corridors, ramps, and toilet conveniences (16).

During our data collection, the human resource division at the MOPH struggled to provide information about physiotherapy public service availability and the number of physiotherapists employed. This is also reflected in the Nepal Health Fact Sheet 2023 (52) derived from the Health Information Management System (HMIS) (53). The health human resource and service coverage section of the fact sheet does not include physiotherapy specific data. The discrepancies in the reports collected in our study on the numbers of registered physiotherapists, highlight the need for a systematic approach and authority to gather reliable baseline information. Despite recent initiatives and policy reforms, we highly recommend proper documentation of the national database of registered physiotherapists and monitoring of physiotherapy services. It is important that policy and decision-makers should not further delay prioritising and promoting physiotherapy services as part of public health services, especially to meet the requirements of remote and underserved areas as reported in studies in other countries (54). One study reported that private practices cannot be sustained in remote areas due to affordability issues (51). Therefore, more public vacancies should be directed to underserved areas. We also recommend that physiotherapy academic schools and professional organisation in Nepal offer additional opportunities to advance the education and skills of physiotherapists to meet demands in areas with identified short supply in compliance with our results and a previous study report (43). This would require financial support to such institutions. We also recommend that physiotherapy stakeholders reconsider low and varied charging systems, referring to practices in other countries (55, 56). To further increase the availability of physiotherapy within the unique Nepalese context, telerehabilitation could be an option for serving rural and remote areas (9).

Strengths and limitations of the study. This is the first multi-site approach in various healthcare settings to assess particularly the availability of physiotherapy services in Nepal. This is also the first study to explore the updated data from registries and different official reports related to physiotherapy. The findings of this study could serve as evidence to inform policy. We believe that the results can be generalised to similar contexts in other provinces of Nepal and help explore further research opportunities in other provinces and healthcare settings. A limitation was that the investigated sites were not evenly distributed, which made it difficult to draw conclusive distinctions between rural and urban settings.

Physiotherapy has the potential to play an important role in the development of healthcare and rehabilitation services in Nepal. This is the first study to examine the availability of physiotherapy services at multiple centres in a selected province in Nepal and explore the available physiotherapy related data in the country. Our study revealed that there is significant variation in physiotherapy service availability among districts within a province and a lack of proper planning for the distribution of physiotherapy workforce nationwide. We recommend the initiation of a national and province-level data registry to inform the distribution of services and human resources in the future. It is also important to monitor and regulate the available services and workforce. Further research is needed to explore physiotherapy services, particularly in remote areas.

CBR

Community-Based Rehabilitation

DOHS

Department of Health Services

MOHP

Ministry of Health and Population

MEC

Medical Education Commission

NEPTA

Nepal Physiotherapy Association

NHPC

Nepal Health Professional Council

OPD

Outpatient department

Acknowledgement

We would like to acknowledge the contributions of all study participants and the human resources and logistical support from NTNU, Norway and Dhulikhel Hospital, Nepal. We thank Ms. Ushnis Shakya for assisting in the data collection and Ms. Sulata Karki from Dhulikhel Hospital for the technical support on the data collection toolkit. We would like to acknowledge the contributions of all the stakeholders at the federal, provincial, and local levels in public and private settings to facilitate this study. The authors would like to thank NEPTA, NHPC, DOHS, MOHP, and all directly and indirectly involved stakeholders for their support.

Authors’ contributions

NRS, AKS, BMK conceptualised the study. NS and research assistant collected the data. NRS analysed the data and drafted the manuscript. NRS, AKS, NT, GW, HM and BMK contributed to reviewing and refining the manuscript. All the authors approved the final manuscript.

Funding

This study was supported by the Department of Neuromedicine and Movement Science, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway.

Declarations

Ethics approval and consent to participate

Ethical approval was granted by the Norwegian Centre for Research Data (NSD 383963), the Nepal Health Research council (NHRC-ERB Protocol No. 455/19) and the Institutional Review Committee of Kathmandu University School of Medical Sciences / Dhulikhel Hospital (IRC-KUSMS 104/18). All study participants provided written informed consent before participating in the study. The handling of personal data was in accordance with the EU General Data Protection Regulation GDPR. The study was performed in accordance with the Helsinki Declaration.

Consent for publication

Not applicable.

Availability of data and materials

Included in the supplementary material.

Competing interests

None declared.

Authors’ information

The authors involved have varying levels of professional qualifications. NS is a senior physiotherapy academician and clinician at KUSMS, former president of NEPTA and a Ph.D. scholar at NTNU. NT is a government employee working under DOHS, Nepal. All the authors are actively involved in national and global collaboration. All the authors have a physiotherapy background, while BMK is an expert in public health and the Nepalese health system. All the authors have significant engagement in global health especially in health promotion, non-communicable diseases, disability, physiotherapy, and rehabilitation.

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Status and availability of physiotherapy in Nepal as reported from facilities and official registers

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