Coverage in Medical and Health Science Curricula in Nepal

Simkhada P1-6, van Teijlingen E5-9, Pokharel T10-13, Devkota B14-15 and Pathak RS16-17 1Senior Lecturer in International Health, School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK 2Honorary Lecturer, University of Aberdeen, UK. 3Visiting Fellow, Bournemouth University, UK. 4Adjunct FacultyDatta Meghe Institute of Medical Sciences (Deemed University) Nagpur, India 5Visiting Professor, Manmohan Memorial Institute of Health Science, Tribhuvan University, Nepal. 6Visiting Professor, Nobel College, Pokhara University, Kathmandu, Nepal. 7Professor, School of Health & Social Care, Bournemouth University, Bournemouth, UK. 8Honorary Visiting Professor, London Metropolitan University, London. 9Honorary Professor, University of Aberdeen, UK. 10Deputy Director of Studies, Nepal Administrative Staff College, Kathmandu Nepal 11General Secretary, Population Association of Nepal (PAN), Kathmandu Nepal 12Board Member, Transcultural Psychosocial Organization (TPO), Kathmandu Nepal 13Managing Editor, Journal of Management and Development Studies 14Reader-Faculty of Education, Kritipur Campus Tribhuvan University Kathmandu Nepal 15DirectorDevelopment Resource Centre, Kathmandu Nepal 16Professor and Head of Central Department of Population Studies, Tribhuvan University Kathmandu Nepal 17President, Population Association of Nepal (PAN), Kathmandu Nepal Chief Editor: Dr. Brijesh Sathian Technical Editor : Dr. Nishida Chandrasekharan Formatting Editor: Bedanta Roy


Introduction
The question of what research component should be incorporated in medical and health science curricula is still contested.In the past few decades, there has been a trend of including a research component in medical and health science curricula to increase students' interest in conducting research and practice evidence-based medicine after their graduation 1 .

Correspondence Author:
Dr Padam Simkhada School of Health and Related Research (ScHARR) University of Sheffield Regent Court 30 Regent Street Sheffield S1 4DA Email: p.simkhada@sheffield.ac.ukThere is wide-ranging inequity in access to health care between the developed and developing countries, which is matched by unequal distribution of health information 2 .Access to the world's collective knowledge, primarily in health sciences and medicine is essential in order to create strong social, economic and technical infrastructures 3 .Access to research information is essential to strengthen practice, to empower local experts to find solutions to health problems and to encourage evidence-based practice.Evidence-based practice is important to deliver high quality care.But, lack of research literature is the most serious obstacle for health professionals and researchers in the developing world.According to a recent World Health Organization (WHO) survey of the 75 countries with a Gross National Product per capita per year of less than US $1,000, 56% of medical institutions have had no subscriptions to journals over the last five years 4 .
Despite the enormous disease burden in Nepal, research is often viewed as an expenditure rather than an investment.Moreover, case studies from Nepal, Bangladesh, and Pakistan report that the bulk of government funding for research goes towards training, salaries, and infrastructure, resulting in research projects being largely funded (and influenced) by external donors 5 .Until recently, most health researchers in Nepal worked individually rather than in institutions.
Nepal has made great progress in health sciences and medical education, e.g.ten Medical Colleges have been established and quite a few are on the pipeline.There are more than 40 Nursing Colleges (both in private and public sectors) and an equal number of other health science colleges which provide health-related courses (e.g., Public Health, Pharmacy and Radiography) are currently functioning in Nepal.There are about 5,000 medical and health sciences students enrolled in those colleges each year and some 1,500 staff are directly involving in their teaching.
Despite this increase in institutions, the overall research environment is still poor 6 .The trend of Nepal-related research publications made by the Nepali researchers in peer-reviewed journals shows quite a limited number of publications compared to their non-Nepali counterparts.The number of publications seems lower in the Government University compared to private universities 7 .The use of evidence-based information in higher education is a must for addressing health-related problems but Nepal's higher education institutions' staff lack knowledge as well as resources for utilising research published even in free and low-priced journals 8 .
Many factors such as poor structural environment and lack of staff, financial and physical resources, might have contributed to inadequate focus on health science research.In addition, limited or no access to research information, particularly the electronic databases, could be one of the main reasons behind a poor research environment in Nepal.Because of expensive subscription fees and complicated licensed agreements, many medical schools and other higher education institutions in Nepal are unable to subscribe the health sciences related journals.This may be supported by inadequate awareness and interest among the health science academics.As a result, many researchers, university teachers and research students in Nepal often have little or no access to the published research literature6.Similarly, health research in Nepal is characterized by weak institutional infrastructures, inadequate funding, the consequent isolation and insularity of a research community against which ideas can be exchanged, leading to an insignificant contribution to the world's knowledge pool.The capacity to absorb scientific and technical knowledge is often weak in Nepal, leading to low levels of scientific output and further underdevelopment.
Limited research8 and our own experiences suggest that many higher education institutions and their researchers including university teachers are not able to access even freely available research literature.Several Nepali postgraduate students from different health backgrounds, despite having strong academic competency, lack necessary knowledge and skills to access research literature, the kind of skills needed to do a proper systematic review 9 .In recent years, there has been several studies looking at the research components in undergraduate medical curriculum 1,10,11,12.This paper is of the first kind to review systematically medical or health science curricula at a national level in Nepal.

Rationale
As the Government of Nepal (GoN) has favoured liberalisation of the education market after the restoration of democracy in 1990, there have been some remarkable developments partly through private involvement in education system.As the result many private institutions now offer higher education in health and medical sciences.With the growing number of institutions, it timely to examine research curricula they have adopted, especially focusing on the access to research literature and its utilisation.
Human resources for health services are key factors if Nepal is to achieve the targets of the MDGs (Millennium Development Goals) health.This article contributes to building the capacity of human resources for health services through promoting their research capacity.Analysing the research component in health science curricula and practices of evidence-based research information in teaching strategy enhances the skills and service delivery capacity of health workers.

Aims and Objectives
This contents analyses aims to analyse the coverage of research methodology components in the curricula of health sciences in higher education and the access to research literature.It also compares the contents of research methodology and access of research to research literatures by level (undergraduate/post-graduate) and by courses.Finally, it identifies gaps in curricula specific to This study analysed published curricula provided by the each university.Some curricula have detail specification of the courses with all information available while others are less structured.For those less structured courses the study team has recalculated the weights synthesising entire course contents.

Analysis
The review is in two sections: first research methodology courses in the curriculum of each programme are reviewed.This includes assessing the coverage of research methodology, weighting and teaching hours allocated.While assessing the contents of research methodology, we have also reviewed whether there are research methodology related contents in other courses than the research methodology course and they have been duly incorporated in the analysis.The second section is more specific to access of research literature in research methodology courses.Curricula are duly examined whether they have mentioned the techniques of accessing the research literature, use of literature database and methods of systematic review.

Findings
This analysis included undergraduate (Bachelor) and postgraduate (Master) courses.The reason behind was that the courses below undergraduate level were less research oriented as elsewhere and the courses above postgraduate were more research based which have no obvious reason to include in the analysis.
Curricula of 105 different programmes were reviewed.The number of programmes at Master's level (74) was more than double than that of Bachelor level (31).Tribhvuan University had the highest number of programmes in health sciences (37) followed by BP Koirala Institute of Health Health Sciences (33) and Kathmandu University (24).Pokhara University had no Master's programme running at the time of our review (Table 1).There are some observed gaps in the health science curricula -a) dissimilar weighting within and across the disciplines; b) dissimilar curricula structure within and between institutions; c) omission of contents on ethical consideration, citation and referencing and systematic review; d) access to research literature; and e) less structured and detailed curricula of clinical and lab based programmes.
The study recommends a number of initiatives to improve the existing higher education curricula of health sciences in Nepal.Our key recommendations are that higher education institutions in Nepal need to review, where necessary revise existing health science curricula to strengthen their research methodology contents.Similarly, curricula should include more contemporary issues in research methodology training.The curricula should include clear instructions to students on how to access the most-up-to-date research literature and how to appraise the research articles.

Table 1 : Course/Programme included in content analysis
PoU), while the weighting in public health varies between 14 and 23%.In Pharmacy, Dentistry, Lab technology, Ophthalmology and Biochemistry-the weighting varies between 2 and 10%.

Table 2 Example Contents of Research Methodology in Undergraduate Programmes
(PoU and PU) miss out citation and referencing and systematic review.Many others (e.g.Medicine, Dentistry, Lab technology and Ophthalmology) have not introduced the topic of ethics in health research.The study finds a common gap in citation and referencing and systematic review in all curricula.Lab based and clinical programmes have less spelled out on research methodology in their curricula.

Table 3 Example of contents of Research Methodology in Postgraduate Programmes
Regarding the contents, seven to eight elements of our indicators were mentioned in the curricula.None of the curricula had mentioned citations and referencing or conducting systematic review.In case of lab-based and clinical programmes, no structured curriculum was available.However, the latter courses had incorporated a mandatory dissertation during the course cycle.Most of curricula contain basic statistics, data analysis package and introductory contents of research methodology.These are important assets for improving access to research literature.Recently introduced programmes, for example Public Health and Nursing in PU and PoU, have better research methodology contents and are more comprehensive in design.