Written by Amy Hutton, ST4 Emergency Medicine, Mersey

Edited by Anisa Jafar, Consultant Emergency & Paediatric Emergency Medicine, Salford Royal NHS Foundation Trust

From the second you step off the plane in Kathmandu you cannot help but fall in love with Nepal. The busy, vibrant streets sprinkled with temples and bursting with local culture entirely immerse you. Famous for its mountain hikes, cultural landmarks and wildlife, Nepal is a popular destination for tourists and adventure-seekers. However, being there with a focus on healthcare creates a reminder of the realities beyond tourism. Nepal is currently experiencing significant socio-economic development, predicted to graduate from a Least Developed County (LDC) to a developing country in November 2026. But despite many impressive advancements, its population of over 29 million is living with a GDP per capita of just 1,447 USD equivalent and social structures including the healthcare system face huge challenges including lack of resources and staff, difficult working conditions, high prevalence of disease and conflicting traditional beliefs .

Healthcare in Nepal is delivered by both private and public sectors, with standards of care varying dramatically between hospitals and regions. The recent increase in government healthcare expenditure included an affordable insurance plan, which has improved access to care for many. Nevertheless – as with many low and middle income countries – hospitals often continue to lack resources and infrastructure to deliver international standards of care, and as of yet Nepal’s healthcare system is yet to attain SDG or national targets.

After my ST3 year in UK Emergency Medicine (EM) training, I took a year out or programme in order to explore opportunities in global health. And that’s how I found myself on those bustling streets, along with two of my anaesthetic friends: Alex and Abhash. Being from Nepal, Abhash had completed his medical training here before moving to the UK. With some well-timed annual leave and very helpful connections, the three of us were about to undertake clinical observerships in the hospitals where he trained. We went hoping to gain experience of working in low-resource environments without quite anticipating where it would lead.

The first hospital we visited was Manipal Teaching Hospital (MTH) in Pokhara. A short flight away from the brilliant chaos of Kathmandu, Pokhara is breathtakingly beautiful. A city built around a lake, alive with shops and cafes, and surrounded on all sides by snow-capped mountains, it’s no surprise that it hosts over 1 million tourists a year – most, in fact, being domestic travellers.

MTH is the largest hospital in Western Nepal, and is a national leader in healthcare and medical education. It boasts an impressive tertiary referral service including neurosurgery, dialysis and 50 critical care beds. Despite its position as a private teaching hospital it is able to provide an accessible service due to affordable health insurance along with fundraising schemes, led by the hospital’s medical students. 

We were met by Abhash’s sister and brother-in-law: prominent clinicians in their fields of Obstetrics and Gynaecology and Neurosurgery. During our time in MTH it became obvious just how much hard work clinicians and the wider government are investing to improve the health of the population: the feeling of growth and advancement in Nepal was palpable. Examples in MTH included improved maternal outcomes, expansion of neuro-intensive care beds and annual onsite training with the Royal College of Surgeons. Despite progress, there remained stark reminders of the challenges faced. Staff were exhausted, often working 36 hour shifts and some essential resources were limited. For example, the emergency department only had access to one unit of blood. Other barriers to accessing healthcare included widespread misinformation leading to health beliefs which hampered evidence-based public health. As one example, one patient relative, who was clearly distressed by his daughter having acquired dengue fever (one of the viral haemorrhagic fevers known to be spread by the Aedes species of mosquito) firmly believed it had been caused by a COVID vaccine.  

We visited a total of five hospitals during our time in Nepal, and although resources and infrastructure varied dramatically, the recurring themes of staff burn-out, lack of local guidelines and safety procedures, and desire for more training was shared between all. It was during our time in B.P. Koirala Institute of Health Sciences – a well-regarded, autonomous teaching hospital in Sunsari (a more rural southern district of Nepal) – that the idea for a longer-term collaboration began to grow. 

One day Alex was between elective surgical cases and he asked where the difficult airway trolley was kept. The anaesthetist smiled, pointing at his junior and said “If we have a difficult airway, he will have to run fast to find the equipment”. We had got used to the humour and resourcefulness of our local colleagues who were simply working day and night to deliver the best care they were able to within a stretched system. However this particular moment struck a chord. It led to a deeper discussion around safety protocols in the UK. Local anaesthetic colleagues were fully aware of the Difficult Airway Society guidelines and WHO checklists however, to implement, train colleagues in, and maintain long term audited use of them, required time and energy. Time and energy was very clearly in short supply. Whilst it was not in our gift to be able to shift the dial enough in the local healthcare system to provide such time and energy, between the three of us, in conversation with some of the senior anaesthetists we put forward a suggestion. What if UK-based clinicians could come to these hospitals not just to work clinically, but to support local colleagues with the leg work required to develop and implement guidelines and protocols?

The engagement and enthusiasm from the various teams we met in the hospitals really galvanised the idea. Together we began to design a partnership programme whereby UK doctors would initially immerse themselves clinically within the department, to begin understanding the local context and learning what the local priorities are before undertaking a project to collaboratively support the implementation of sustainable change. It was through these discussions that OCEAN was formed. 

Since our trip to Nepal in October 2024, we have established OCEAN as both a limited company and a registered charity. We have built working relationships with two hospitals in Nepal and together we have devised our Clinical Partnership Programme (CPP). The model is of a 3 – 6 month placement for EM, Anaesthetic and Critical Care senior clinicians to work within these hospitals with the goal of supporting local clinicians to build sustainable practices. We are about to begin our first recruitment of doctors from the UK, something that both our UK and Nepalese teams are extremely proud of and excited about.

Getting OCEAN established has been a huge, and at times, daunting learning curve: we are incredibly grateful for the invaluable support from those with legal and financial expertise alongside medical colleagues.  We have committed to ensuring we have the correct government status and have trustee involvement and legal frameworks in place to safeguard everyone involved – whilst good intentions can carry you so far, doing this professionally and to a high standard requires the correct process.  Recruiting will represent its own challenge. We will host interviews alongside the respective department lead from Nepal to ensure we select those who represent our values and can maintain a relationship of respectful partnership and collaboration with our colleagues. The lessons we learn along the way will help in the ultimate longer term aspiration to create full exchanges whereby colleagues from Nepal mirror the same role within the UK. Government restrictions on UK visas are one of many hurdles to achieving this, however in collaboration with other organisations we believe we will eventually get there especially with precedents such as RCEM’s Visiting Observer Fellow Scheme.

It is hard to describe the experience I had in Nepal, the places I have visited and the people I have met will stay with me for life. To come away with an opportunity to support colleagues to evolve their acute healthcare provision at such a pivotal time in the country’s development is an incredibly exciting prospect and a real privilege. If you would like to hear more about OCEAN or are considering applying for our CPP then please visit our website www.oceanglobalhealth.com or get in touch: [email protected].