Background
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 many other 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, where the healthcare systems differ between 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]. For instance, USAID Physical Rehabilitation Activity along with Handicap International, in partnership with the Government of Nepal, supports 5 private physical rehabilitation centers and 19 public sector physiotherapy units [
20]. Private service provision is considered crucial in the field of physiotherapy [
21,
22]. Despite the increasing use of private facilities in Nepal [
23], 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 [
24]. 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 [
25]. Registered physiotherapists, with a minimum of bachelor’s degree, are represented by the Nepal Physiotherapy Association (NEPTA) [
26,
27]. 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 [
27]. Regrettably, attrition of physiotherapy has become a major issue that impacts the overall profession and its future. Unsatisfactory working conditions and lack of carrier development opportunities leads to migration to high-income countries for employment and education [
28].
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 [
29]. Its objectives include providing preventive, promotive, and curative health services, providing technical advice for health policies. It is also responsible for developing and expanding health institutions, determining manpower requirements, encouraging participation from the private sector and international institutions. Additionally, coordinating and controlling the quality of health services, and maintaining data and information on health services [
29].
Despite these efforts, Nepal still faces challenges in implementation resulting in huge gaps between plans and actions in all sectors [
30]. 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 province-level survey in combination with exploration of official records was undertaken. The survey aimed to assess implementation of physiotherapy services in different health facilities in a selected province. The assessment was focused on objective measures that could be verified such as type of services, human resources, charging and documentation systems, and accessibility. Official records were explored for policies and plans, and the general status of physiotherapy with regard to development in workforce, education, facility and resource allocation, law and regulations. The outcome was expected to reveal the current status of physiotherapy services in the perspective of governing policies and plans.
Discussion
This study provides the first comprehensive overview of physiotherapy service provision in Nepal. Inconsistencies in baseline data on the number of registered physiotherapists call for the need of systematic records. The survey revealed significant geographical imbalances and varying levels of availability and distribution of physiotherapy within Province III. Our findings have implications for decisions on resource allocation and contribute to facilitating more logical physiotherapy allocation and may serve to guide implementation in other provinces.
Our study supports the notion that physiotherapy services are primarily concentrated in urban health settings, as reported in previous study by Nepal et al. (2022) and for other countries [
10,
22,
28]. This finding corroborates a previous report in which 71% of physiotherapists in Nepal were found to be concentrated in Province III [
31]. 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 [
48]. However, the limited availability or lack of physiotherapy services in rural districts despite significant population density, as reported in our study, could be due lack of prioritization or awareness about the service, or lack of attracting working conditions [
49].
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 [
49]. This may also be reflected in a Canadian study that indicated physiotherapists generally assume a generalist role, providing different clinical services to their patients [
50]. 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 [
51], DOHS [
52] 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 [
26].
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 [
53,
54] could contribute to increased availability and a reduced healthcare burden on doctors without significant risk to patients [
55,
56]. The present study also revealed inconsistent and varied charging systems in most of the physiotherapy facilities, raising concerns about the quality of services and out of pocket costs. Unpredictability in charges is a serious concern particularly for the 15.1% of Nepalese population reported below the poverty line with a daily purchasing capacity at < $1.90 [
57,
58]. Gross salary ranges between 15,994 and 60,346 Npr [
59], where one income often sustains a large extended family [
60]. Unemployment was in 2022 estimated to 11.1% [
61]. Predictable and fair charging systems need to be reconsidered by stakeholders exemplified by practices in other countries [
62,
63]. 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 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 [
64] derived from the Health Information Management System (HMIS) [
65]. 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, implicates the need for a systematic approach and authority to gather reliable baseline information. Despite recent initiatives and policy reforms, we still emphasize the need of proper documentation in the national databases on 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. This is particularly important to meet the requirements and needs in remote and underserved areas [
66] where private practices cannot be sustained partly due to affordability issues [
56]. In compliance with our results and others [
48], physiotherapy academic schools and professional organisation in Nepal need to advance education for skills to meet demands in areas with identified short supply. Financial support would be required for such initiatives. To further increase the availability of physiotherapy within the unique Nepalese context, telerehabilitation could be an option as a supplement 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. A limitation was that the investigated sites were not evenly distributed, which made it difficult to draw conclusive distinctions between rural and urban settings. Still, the findings hold internal validity serving as evidence to inform policy and planning in Province III. We also believe that the results can contribute to direct attention toward challenges in implementation of physiotherapy services in Nepal, although external validity may be compromised due to significantly lower density of physiotherapy service in other provinces and differences in provincial health systems organization.
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.