Understanding key components for strengthening Nepal’s healthcare wants: well being methods views

Nepal has made important progress over the previous few years when it comes to well being indicators.1 This spectacular achievement in well being indicators is the results of strengthening the first (largely peripheral) well being care (PHC) methods, significantly via investments to ascertain well being care infrastructure and well being methods strengthening.2 As a signatory to the Alma Ata Declaration in 1978, the federal government of Nepal recognised the significance of major healthcare approaches within the growth of coordinated high quality healthcare companies for folks dwelling in city and rural areas.3

Remodeling well being methods to fulfill the Millennium (MDGs) and Sustainable Improvement Purpose (SDGs) replicate how globalisation has inspired well being methods to undertake these targets. Toddler mortality declined by two-thirds from 78 in 1990 to twenty-eight deaths per 1000 dwell births in 2022, whereas maternal mortality declined by half from 543 to 151 deaths per 100,000 dwell births from 1996 to 2021.4–6

Entry to well being care has considerably improved over time, but disparity primarily based on socioeconomic standing and site persist. As an example, the institutional supply price has improved from 18 % in 2006 to 39 % in 2011 to 79% in 2022.4 The institutional supply for the bottom wealth quintile was 65.8 % whereas that of the very best wealth quintile was 97.6 %.4 Although births aided by expert beginning attendants elevated from 19 % in 2006 to 80 % in 2022, solely 67 % of ladies within the lowest wealth quintile accessed SBA in comparison with 97.4 % of ladies within the highest wealth quintile.7

Well being methods in low- and middle-income international locations (LMICs) can endure from extra burden of illness as a consequence of insufficient preparedness, and weak major well being care system that may finally improve morbidity and mortality.8,9 Whereas, major healthcare could be a vital part for attaining the SDG targets.10 Regardless of the improved indicators, Nepal’s well being methods is but to realize SDG and nationwide targets as a consequence of numerous causes.11,12 Contemplating this, there’s a want to research and perceive the components influencing service supply and total well being outcomes.

Though systematic evaluations seem to learn in accumulating knowledge concerning limitations and facilitators related to well being methods functioning, the complexity of the well being methods, companies, and operationalities current distinctive challenges in evaluating and mixing these quite a few components. This paper goals to current well being methods views by reviewing the well being methods functioning of Nepal, discover the components important for the development of nation’s healthcare wants and forge actionable suggestions for future.

The narrative evaluation adopted the Most popular Reporting Objects for Systematic Critiques and Meta-Analyses (PRISMA) tips for figuring out the related literature.

Search Technique and research choice

A complete of 300 related abstracts together with nation experiences, nationwide surveys had been obtained from the preliminary search, from which 42 full textual content articles together with nation experiences had been chosen for an in-depth evaluation after screening the search end in three levels: a) scanning their titles; b) summary screening; and c) full-text screening. The research included within the evaluation pertained to: Well being methods in Nepal and expenditure on healthcare in Nepal, Illness Burden, international burden of illnesses in Nepal and SDG indicators adopted by Nationwide Stage experiences of Nepal and survey experiences.

Exclusion Standards

Articles which had been unrelated to matter involved, research or literature in languages apart from English, and didn’t fulfill the evaluation objective had been excluded.

Inclusion Standards

42 peer reviewed articles together with nation experiences revealed from 2001 and 2023 had been included for our ultimate evaluation.

The search phrases included ‘well being methods AND ‘Nepal’ AND ‘Well being coverage’ AND ‘SDGs’ AND ‘healthcare’ AND ‘expenditure’ AND ‘nationwide survey’ AND ‘international burden of illnesses’ AND ‘well being indicators’ AND ‘Nationwide applications’ AND ‘monetary schemes AND ‘Major well being care’ AND ‘Nationwide Well being technique’ AND ‘Nepal well being experiences. This search technique was used to establish revealed papers in PubMed, ResearchGate and Google Scholar and Cochrane.

This narrative synthesis follows an iterative course of for exploration of related literature and synthesis of main findings utilizing parts and elements of Nepal well being methods and its functioning. Last 5 themes had been chosen and are offered within the outcomes part – Theme-A: Historic growth in well being care supply system; Theme-B: Present state of affairs of well being methods; Theme-C: Well being expenditure in Nepal; Theme-D: Well being methods challenges; Theme-E: Alternatives and approach ahead.

A. Historic Improvement in Healthcare supply system in Nepal

A revolutionary change within the well being construction of Nepal was marked by the institution of Bir Hospital in 1889 which introduced in regards to the growth of Nepal’s trendy medical system. Nepal’s first normal well being plan was launched in 1956 as part of First five-year plan adopted by the institution of Malaria Eradication Group in 1955.13

Following which, in 1958 and 1968 Leprosy and Tuberculosis, and the Smallpox Eradication applications had been launched. The Household Planning Program launched in 1966 was reworked into the Household Planning and Maternal Little one Well being Board in 1968.14

Shifting to broader framework, Nepal launched first 15-year long run well being plan in 1975 adopted by second long run well being plan in 1997. Moreover, Nepal additionally grew to become a signatory to Alma Ata declaration in 1978 increasing the strategy to bettering well being for all folks from the give attention to medical doctors, hospitals and biomedical advances to incorporate human rights, concern for fairness and group participation.15 Imposing and strengthening the position of presidency in Well being methods strengthening, Nepal launched its first Nepal Well being Coverage in 1991 to handle the aspirations of individuals, underneath which sub well being posts in village growth committees, well being posts in numerous areas and one major well being centre in every electoral constituency had been established.13 The coverage harassed upon structural growth and enlargement of well being companies to village areas and involvement of personal sector in well being. The well being coverage was revised in 2014 when the main target was expanded to make sure provision of free fundamental well being companies to the residents.

In 2018, as a part of the WHO member state, Nepal grew to become one of many international locations to signal the Astana declaration and pledged to strengthen its major well being care system as a vital step in direction of attaining common well being protection.16 This was adopted by restructuring of Nationwide Well being Coverage in 2019 with the purpose of growing and increasing a well being system for all residents within the federal construction primarily based on social justice and good governance, in addition to making certain entry to and utilisation of high quality well being companies.13

B. Present Situation of Well being methods in Nepal

Nepal’s well being coverage surroundings and health-care supply system have modified during the last 25 years. There was a radical shift within the functioning since 2008 when the unitary authorities moved to a federal system. Consequently, the nation’s well being system’s administration construction has shifted from centralised to decentralised, leading to extra administration buildings on the district and village growth committee stage (VDC) ranges, adopted by adoption of the Structure in 2015, by which fundamental healthcare was established as a elementary proper of its citizen.

The brand new federal system has three tiers of well being whereby the Ministry of Well being and Inhabitants (MoHP) is the umbrella physique. MoHP together with the Division of Drug Administration, Division of Well being and Household Welfare and Division of Ayurveda types the federal stage or the decision-making physique for well being insurance policies and plan.17

A number of regulatory our bodies such because the medical, nursing, pharmacy, well being skilled, Ayurvedic Medical and Nationwide Well being Analysis Councils have been lively in making certain high quality well being companies, evidence-based well being analysis and human assets for well being. (See field 1)

Box 1

Field 1.Stage of care in Nepal

This decentralised organisation, in addition to the gradual enlargement of well being companies, starting with the supply of fundamental household planning companies and progressing to the supply of kid well being medicines and life-saving maternal well being companies resulted within the availability of a complete bundle of maternal and little one well being (MCH) companies on the group stage.18 Following the provision of free fundamental healthcare companies and insurance coverage schemes, Nepal has been faring nicely when it comes to its efficiency in attaining Sustainable Improvement Objectives. The fifteenth Improvement Plan (2019/20-2023/24) guided by the overarching nationwide imaginative and prescient of a “Affluent Nepal, Completely satisfied Nepali” has mainstreamed the SDGs. Their targets, targets, and milestones are all internalised within the 25-year long-term imaginative and prescient 2100 (Nepal Calendar). There have been main enhancements in nation’s well being indicators similar to decline within the fertility, malnutrition, and mortality charges (Desk 1). A number of the milestones achieved by the nation embrace eradication of maternal and new-born tetanus, leprosy, and trachoma; management of assorted communicable and infectious illnesses; and institution of regulatory our bodies for well being analysis and healthcare professionals. Moreover, SDGs have been integrated into the periodic plans of Sub-Nationwide Governments, with efficient monitoring and evaluation procedures.

Desk 1.Well being Indicators of Nepal and SDG

Indicators Nepal
Nepal 2022b International SDG 2030c
Maternal Mortality Ratio (per 100,000 dwell births) 229 151 223 (UNICEF 2020) 70
Underneath-five mortality price (per 1000 dwell births) 54 33 37 (UNICEF 2021) 20
Neonatal mortality price (per 1000 dwell births) 33 21 18 (UNICEF 2021) 12
Toddler Mortality Fee 46 28 28 (WORLD BANK 2021)
Complete fertility price (births per 1,000 ladies aged 15–19 years) 2.6 2.1 2.3 (WORLD BANK 2021) 2.1
Prevalence of stunting in youngsters underneath 5 years % 41 25 22.3 (UNICEF 2022) 15
Institutional supply% 35 79 76 (UNICEF-2020) 90

a2001–2016, Nepal Demographic and Well being Survey (NDHS)
bNepal Demographic and Well being Survey (NDHS) ** Nepal A number of Indicator Cluster Survey (NMICS) 2022
cNationwide Assessment of sustainable growth targets, report 2020, govt of Nepal

C. Well being Expenditure in Nepal

As Nepal strikes ahead with its new federal mannequin, there’s a constructive outlook for the potential speedy improve in public well being expenditure. This bodes nicely for the nation’s journey in direction of attaining Common Well being Protection and making certain the well-being of all its residents. Nepal has made important strides in its healthcare system. Though the full well being expenditure (THE) accounted for 4% of GDP in 2019, there’s room for progress, particularly contemplating the baseline of 5.3% in 2010.7,19 The various funding sources, together with taxes and contributions from exterior donors, show a collaborative effort in bolstering the healthcare sector. In 2020, the per capita Public Well being Expenditure (PHE) elevated to USD 58 from USD 10 in 2001 rising at a mean annual price of 10.03%, reflecting a dedication to offering high quality healthcare for its citizen, indicating a rising self-sufficiency in funding healthcare companies.20,21

Nepal additionally has distinctive strategies for pooling funding for the MOHP programmes, which straight help the poor and are important in eliminating disparities in entry to healthcare companies similar to a) Secure Motherhood Program to cut back maternal and neonatal mortality and morbidity via preventive and promotive measures and addressing components inflicting demise throughout being pregnant, childbirth and post-partum interval22; b) Free Healthcare: for residents to entry district hospitals and first well being care centres with out paying any registration payment, free outpatient, emergency and inpatient companies in addition to medicine; c) Impoverished residents companies program to offer medical remedy to the disadvantaged and impoverished sections of the society; and d) Mattress-for-the-Poor Initiative to allocate 10 % of beds in non-public hospitals to the poor freed from cost.21

D. Well being methods Challenges in Nepal

Shortfall in well being methods inputs

Well being methods want important inputs and requisite help methods to facilitate efficient and environment friendly healthcare service supply whereas additionally making certain its high quality, acceptability, and utilization. The 2021 nationwide survey highlighted shortfall in well being methods inputs hampering service availability. As an example, although most well being amenities (96-99%) supplied fundamental reproductive and little one well being care, solely 5 % have the capability for caesarean deliveries. Provisions for prognosis and treating malaria, HIV and prevention of mom to little one transmission have declined over time. Lower than one-third (17%) of all amenities have facilities thought of fundamental to the supply of shopper companies and amongst them, the share of fundamental well being care centres was minimal (9%). Round 41% of amenities had all gear thought of fundamental for offering high quality companies. Primary diagnostic testing capability was supplied in solely 17.9% of well being amenities, and advance exams had been largely out there on the stage of Zonal hospital or above. Although majority of public hospitals had pharmacy companies (87%), the provision of medicines throughout the degrees of care was differential. The general public amenities continued to face staffing shortages, significantly within the City Well being Centres (18.7%) and the Group Well being Models (7.8%).7

High quality of care

The provisions for making certain minimal high quality of care requirements on the level of service supply, similar to an infection management, biomedical waste administration, availability of facilities, medicines, skilled staffs, and tips had been variable throughout the nation. The Nepal Well being Facility Survey (NHFS) 2021 report estimated their availability in lower than 1 % of amenities.7 Lower than one-third of well being amenities (23.2%) reported any high quality assurance exercise, with shopper suggestions system operational in solely 4 % of them.

Well being workforce

Availability of expert human assets is crucial for a rustic to offer high quality and inexpensive healthcare companies to its residents. In line with World Well being Group’s suggestion there ought to be 45 well being personnel (medical doctors, nurses, and midwives) out there for each 10,000 folks, whereas, Nepal has 34 out there well being specialists for each 10,000 people within the nation.23 As per NHFS 2021, the PHCCs (74.7%) and the well being posts (76.7%) have extra sanctioned HRH positions crammed as in comparison with the district stage (69.7%) and zonal stage and above (68.8%) amenities.7 Between 2015 and 2021, Nepal witnessed important shifts in its healthcare workforce composition. In 2015, nurses and paramedics accounted for a considerable 36% of the healthcare workforce. Nevertheless, by 2021, this proportion plummeted to a regarding 0%, indicating a stark decline within the variety of frontline healthcare employees. Furthermore, in 2021, nurses and paramedics constituted solely 18.7% of the healthcare workforce, a notable drop from the 29% reported in 2015. Geographically, the distribution of Medical Officers (MOs) revealed fascinating pattern, the place the hill area boasted the very best share of MOs at 60%, whereas the terai area adopted with 45.8% and the mountain area, conversely, exhibited the bottom proportion of MOs at 27%. This regional variation means that educational incentives for distant postings could have performed a big position in bolstering MO availability within the hill area. Moreover, the diminished presence of frontline well being employees on the group stage could be attributed to Nepal’s difficult topography, which poses substantial obstacles in making certain accessible and high quality healthcare, significantly in rural areas. These findings underscore the necessity for focused insurance policies and interventions to handle these workforce disparities and enhance healthcare entry throughout Nepal.22,24

Elevated expenditure on Well being

The nation receives monetary help for well being companies via numerous multilateral/exterior sources which is crucial for the functioning of well being methods as a consequence of rising price of well being care and expenditures. On common, exterior financing contributed 17 % of present Well being Expenditure (CHE) in Nepal (2000-2017), whereas out-of-pocket spending accounts for almost 3.2 % of GDP (2018). Budgetary and monetary points that coexist with structural and policy-level construction are obstacles to well being service supply.23 The dearth of public-private partnerships within the supply of well being care and incongruous efforts between the federal government and non-governmental organisations additional complicate the scenario and doubtlessly hinder attaining SDG targets.24

Elevated Mortality

Regardless of the features in nationwide well being indicators, there stays a big burden of communicable, maternal, neonatal, and dietary (CMNN) illnesses (29.26%). That is additional compounded by the rising burden of non-communicable illnesses within the nation (61.18%).25 The entire variety of deaths in Nepal for the yr 2019 was estimated to be 193,331. Of those, 71.1 % (95% UI: 67.3-73.8) had been as a consequence of NCDs whereas remaining 21.1% (95% UI: 18.5-24.8) and seven.8% (95% UI: 6.9-8.8) had been as a consequence of CMNN illnesses and accidents, respectively. NCDs had a mortality price of 452.2 (95% UI: 379.9-510.3) deaths per 100,000 inhabitants whereas for CMNN illnesses and accidents had been 133.8 (95% UI: 112.3-162.3) and 49.6 (95% UI: 38.8-60.0) deaths per 100,000 inhabitants respectively indicating a necessity for concerted efforts in direction of decreasing the rising illness burden of NCDs.25

E. Alternatives and Method Ahead

Nepal’s health-sector-strategy envisages equitable entry to high quality well being companies, well being sector reforms and multi-sectoral strategy to attain sustainable growth targets. Given the contextual components in Nepal’s well being methods, proof from different growing international locations and related settings could also be thought of for localized adaptation to strengthen the well being methods and speed up its present practices throughout provinces throughout the nation, in direction of SDGs and Common Well being Protection (UHC).

Organising service supply

The governmental restructure favourably disposes the nation to strengthen a decentralized major healthcare supply system. The Feminine Group Well being Volunteers (FCHVs) within the nation play an necessary position and could be a focus for group participation and mobilization in direction of elevated well being in search of behaviour. To strengthen the group processes and engagement, due consideration is required for putting and constructing the capability of those frontline employees throughout numerous areas. Supply of complete major well being care could be streamlined by efficient utilization of recent and present community-based platforms.

The demand generated for companies on the group stage could be met via gradual strengthening and enlargement of duties of FCHVs; making certain logistical help via demand-driven and decentralised ordering and distribution system; rising availability of commodities; streamlining reporting processes; and thru incentives (financial/non- financial) to inspire the workforce on the group stage.26 Strengthening of companies on the major stage should additionally embrace concurrent enlargement and strengthening of secondary and tertiary stage amenities to make sure strong referral linkages and continuum of care. Additional, the continuing enlargement of service supply websites and introduction of telemedicine companies have the potential to bridge constraints to care entry.27–29

With the purpose of total well being methods strengthening, the nation would wish to combine the long-standing vertical applications with horizontal and community-based well being companies.30 The well being features in maternal and little one well being4 should be sustained, with the main target of mitigating the burden of preventable illnesses. The well being methods should additionally deal with the twin burden of non-communicable illnesses and different infectious illnesses. An total profit bundle could be ideated to embody preventive and promotive measures, early prognosis, referral, and continuum of look after main well being companies together with NCDs, whereas additionally making certain monetary safety. Entry to high quality medicines and applied sciences could be improved via home manufacturing and regulation of their provide, storage, and distribution.31 Whereas making certain entry, the system ought to have skilled-personnel, scientifically-backed forecast mechanisms to fulfill demand, normal remedy tips together with scientific pathways to manage provide. Entry to diagnostics could also be facilitated via a hub and spoke mannequin by linking major stage amenities to larger stage amenities.

Enhancing the standard of care

Well being methods strengthening within the type of fiscal increase, enlargement of well being infrastructure, service bundle, entry to high quality medicines, healthcare applied sciences, diagnostic companies and human useful resource availability are mandatory preconditions for bettering high quality of well being companies.

Varied high quality enchancment initiatives embrace bettering the effectivity of hospitals, coaching and ability mixture of the HRH, and selling applicable know-how.32 Such initiatives should replicate fairness in entry and affected person centricity in care. High quality of well being companies and affected person security at amenities could be ensured via requirements for an infection prevention practices, remedy protocols, healthcare waste administration, and thru protocols for rational prescription of medicines and diagnostics. It might be additional established via high quality accreditation of well being amenities.

Given the coverage stage articulation on high quality assurance of well being companies (2006), the standard enchancment system could also be strengthened with the assistance of a complete, clear, and constant Nationwide High quality Management Framework within the nation. District stage high quality assurance teams could also be constituted to oversee adherence to high quality requirements in each private and non-private sectors.30,31

Addressing HRH necessities

There’s a want for evidence-based mapping of human useful resource requirement in any respect ranges of care. On the group stage, FCHVs are essential to enhance service-reach. Although there are FCHVs current in over 97 % of rural wards, in view of the increasing population-based programmes, a further 25 % FCHVs could be wanted to increase ample companies and help.33 For that, a mapping train will assist the well being methods gauge their positioning as per the inhabitants requirement. Concurrently, the duties of FCHVs could also be expanded to enhance entry to important companies, for referral and continuum of care.

For maintaining with the epidemiological transition and rising demand for major healthcare companies in resource-constraint settings, proof suggest the event of interprofessional groups, integrating activity shifting and activity sharing mechanism throughout the system and the event of recent skilled fields as methods to beat service supply shortfall as a consequence of staffing scarcity and maldistribution of human assets. Enhancing the provision of nurses and different non-medical well being professionals on the major stage would enable shifting of duties from the physicians/ medical officers, with out compromising the standard healthcare, affected person security, shopper satisfaction and well being outcomes. An expanded group would additionally assist bridging gaps in accessing companies throughout socio-economic teams and areas.34–38

The lively workforce should be supported with capability constructing measures like pre-service and in-service trainings, diplomas in recognized specializations, persevering with medical training, distance training modalities, and coaching programmes on competency-based curriculum.39 Moreover, establishments for HRH coaching (nurses, mid wives and allied well being professionals) also needs to be established for rising their data base. Incentives (financial and non-monetary) to draw and retain expert HRH in troublesome space postings, and to speed up well being outcomes could also be launched.39

Strengthening governance and convergence

The present governance construction presents ample alternatives for strengthening the well being sector. Presence of domestically elected governments and political-will are extremely decisive to intensify well being sector accountability, transparency and scale back delays in implementation. The devolution and the introduction of sub-national treasury regulatory system (SuTRA) widens the scope to shift the emphasis in direction of needs-based planning and useful resource outcomes.17,40 Preventable well being dangers or social determinants of well being want multi-sectoral interventions.39 On the native stage, village growth committees/ gaunpalikas should be strengthened capacitated to handle well being hazards or disasters, to organize well being catastrophe administration technique, and to strengthen well being catastrophe response methods. To attain this finish, capability growth mapping, establishment of multi-stakeholder discussion board in any respect ranges of governance and grievance redressal at native stage are important.17

Collaboration with non-state actors could also be tried to develop entry to diagnostic companies, emergency transport, blood banks, coaching, ability growth, and so forth. Regardless, any strategic partnership is strongly beneficial to be introduced underneath authorized and regulatory frameworks to enhance its legitimacy, accountability and transparency.31

Leveraging data administration methods and e-health initiatives

Availability and completeness of knowledge captured via the knowledge administration methods are necessary to observe the well being system’s effectivity and to drive knowledgeable decision-making processes. The system should be backed with a disaggregate database (geography, social teams) to tell applications and insurance policies.

The nation can make the most of the present e-health initiatives for data administration and companies. The momentum gained on teleconsultation companies in the course of the pandemic could also be leveraged to develop its attain and uptake similar to India’s Nationwide Teleconsultation companies.41 Telemedicine initiatives on related strains should be backed with nationwide tips for optimum operations and supervision.28 Enchancment in digital panorama wants multi-sectoral motion, whereas well being sector can guarantee entry to digital gadgets to its manpower for knowledge seize and administration. Expert HR and customers of companies should be supported with periodic refresher coaching to realize familiarity with the digital fora.

Implementational challenges could be circumvented by having IT-contingency plans, and thru strategic collaboration with technical companions to construct nationwide capability and facilitate intra-regional customisation. Nevertheless, in-country capability constructing, institutionalization of the knowledge administration methods (well being data methods, digital report system, e-reporting, and e-monitoring methods), and integration of IT-based platforms for interoperability are essential for sustainability.41

Strengthening well being methods analysis

Coverage making and monetary choices ought to be proof primarily based and context particular. Prioritising implementation analysis in direction of focus areas as recognized by the Nepal Well being Analysis Council42 can even be instrumental in not solely figuring out gaps or alternatives, but additionally in strengthening programme implementation, and endeavor course corrections.42 Proof may help translate public opinion into coverage whereas additionally promote an efficient stewardship perform in well being methods efficiency and administration.39

The evaluation of Nepal’s healthcare system presents a vivid image of its evolutionary trajectory, emphasizing the pivotal position of latest governance modifications and the adoption of major healthcare methods. These developments signify a dynamic response to evolving healthcare wants. The shift in direction of preventive and community-based care, alongside modifications in how healthcare is organized, underscores a proactive strategy to bettering well being outcomes. This progressive shift opens new avenues for constructing upon present initiatives. The decision for domestically tailor-made interventions in service supply, high quality enhancement, and workforce planning underscores the popularity that healthcare options should be context-specific to be actually efficient. This tailor-made strategy acknowledges the various healthcare panorama inside Nepal, making certain that interventions resonate with the distinctive wants of various communities and areas. Furthermore, the evaluation underscores the potential for accelerated progress in direction of vital international well being targets, such because the Sustainable Improvement Objectives and Common Well being Protection. This underscores the transformative potential of strategic, focused healthcare interventions. Lastly, the evaluation emphasizes the need of a cohesive, built-in technique, involving all key stakeholders within the healthcare ecosystem. This collaborative strategy ensures that assets are optimized, and efforts are aligned in direction of overarching targets, similar to equitable entry, high quality care, complete protection, and monetary safety. In essence, the evaluation provides a complete roadmap for advancing Nepal’s healthcare system, grounded in a nuanced understanding of its present state and the potential for significant progress.


This paper was developed primarily based on the particular course conceptualised for senior officers of Nepal by Indian Technical and Financial Cooperation, Ministry of Exterior Affairs, Authorities of India for commissioning Worldwide Public Well being Administration Improvement Program (IPHMDP) organised by PGIMER Chandigarh.


No funding was acquired to help with the preparation of this manuscript

Authorship contributions

AK and ND conceptualized and outlined the mental content material of the paper. ND, AG and EH contributed to manuscript preparation, enhancing and evaluation. AK and ND critically reviewed the manuscript and finalized the paper. SG helped in designing the course and supported in offering inputs for themes and construction of the evaluation. The paper has been learn and accredited by all authors.

Disclosure of curiosity

The authors accomplished the ICMJE Disclosure of Curiosity Type (out there upon request from the corresponding writer) and disclose no related pursuits.

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