Integrating Social Determinants into Health Workforce Education and Clinical Training - A Case Study: Nepal

In Nepal, the Local Health System Sustainability Project (LHSS) identified Patan Academy of Health Sciences (PAHS) as a model institution that has successfully integrated SDoH into pre-service education curricula for physicians, nurses, and public health professionals. PAHS, established in 2008 in Lalitpur, is a public not-for-profit higher education institution that works in close partnership with the national health system to improve healthcare services in remote and rural areas. The institution provides degrees in medicine, nursing, and public health, with a focus on producing technically competent and socially responsible healthcare workers. The Government of Nepal (GoN) covers operational costs but pays the tuition of 75 percent of undergraduate students in medicine and nursing and 100 percent of post-graduate students in medicine, nursing, and public health through scholarships. The annual intake of undergraduate medical students is 65, and post-graduate is 50. The intake for undergraduate nursing students is 40, and 28 for a master's. Since 2020, the GoN requires candidates for all education programs at PAHS to be selected from the merit list on the Medical Education Commission's common entrance examinations. A certain number of seats are reserved for students from rural areas. PAHS has integrated SDoH into its curriculum through various activities, including home visits, community diagnosis, and clinical service. Students are required to work with Female Community Health Volunteers (FCHVs) to collect data on major diseases and SDoH. They also prepare reports on SDoH for the population of a poor urban neighborhood and work with FCHVs to collect data on major diseases and SDoH. The institution's approach to health professional education is centered on community-based learning, which aims to produce a health workforce ready and willing to work in underserved areas. PAHS has adopted a competency-based education approach, which focuses on developing the skills and knowledge required to address the needs and SDoH context of rural underserved populations. The integration of SDoH into PAHS's curriculum has been successful in producing graduates who are equipped to address the complex factors that influence the health of patients and communities. The institution's approach has been recognized as a model for other health education institutions in Nepal and globally. The National Human Resources for Health Strategy (2021-2030) seeks to ensure the equitable distribution and availability of a quality health workforce, as per the country's health service system. However, the strategy has not yet been fully implemented. The integration of SDoH into health workforce education and clinical training is critical to achieving Universal Health Coverage (UHC) in Nepal. In Nepal, the Ministry of Health and Population (MoHP) provides 67 percent of health services, private providers cover 26 percent, and nongovernmental and faith-based organizations provide 3 percent of services. The country has made great strides toward achieving UHC and in reducing maternal, infant, and under-five mortality. However, disparities persist within the country, with the national average for under-five mortality per 1,000 live births being 39, while it is 63 in Nepal's mountain region. The shortage of skilled health workers and poor staff retention, particularly in rural areas, lack of professional capacity development activities, and inadequate funding are major challenges for the health workforce in Nepal. The variability in the quality of this workforce is caused by, among other reasons, insufficient health workforce planning and inadequate quality control mechanisms in health workforce education.