Paediatric nurses are the backbone of children's health care in Nepal. In hospital wards nationwide, their expertise and compassion save young lives daily, especially in intensive care units where every second counts. These nurses operate advanced medical equipment, monitor fragile infants, and comfort families during challenging moments. Their presence is essential, yet Nepal is losing them at an alarming rate to opportunities abroad – a crisis that threatens the health and future of the nation's children.

The phenomenon, widely known as brain drain, is driven by low salaries, limited career growth, and challenging work conditions at home. Around 2,000 Nepali nurses leave for countries like the UK, Australia, and Canada every year, seeking better prospects. Over half of nurses surveyed in Nepal say they intend to migrate. This exodus is especially damaging because paediatric nurses possess unique skills that are hard to replace. They manage complex conditions like congenital heart defects and non-communicable diseases, which now account for two-thirds of all deaths in Nepal. Their ability to quickly stabilise a newborn struggling to breathe or to adjust a ventilator for a child with heart disease can mean the difference between life and death.

Beyond technical skills, these nurses bring empathy, patience, and resilience. They interpret non-verbal cues from children too young to speak, offer comfort to frightened patients, and support parents facing devastating diagnoses. In places like Jhapa, with a population of two million, paediatric nurses collaborate closely with doctors to provide comprehensive care. Their sharp decision-making and emotional intelligence shine in busy wards, where they juggle multiple patients, manage equipment shortages, and maintain focus under pressure.

The shortage of paediatric nurses is felt most acutely in rural areas, where health care access is already limited. Here, these nurses often serve as the primary and sometimes only caregivers for children with serious illnesses. Only 8 per cent of nurses in Nepal have access to specialised paediatric training, making the loss of experienced staff even more devastating.

Nepal's nurse-to-patient ratio is just 2.2 per 1,000 people, far below the recommended 4 per 1,000. This shortage is a key factor behind the country's under-five mortality rate, which was 28 per 1,000 live births in 2020. Staffing gaps strain hospitals, leading to burnout among remaining nurses and fueling the migration cycle. The financial impact is also significant: nurse migration costs low-income countries like Nepal over a billion dollars annually in lost investment and productivity.

The impact of brain drain is particularly severe for children suffering from chronic illnesses. Diseases like rheumatic heart disease affect up to 2 per cent of school-aged children in Nepal. Without enough trained paediatric nurses, hospitals struggle to provide timely treatment. Overworked nurses are stretched thin, increasing the risk of mistakes and discouraging talented professionals from staying in the country. The emotional toll on families is immense, as parents often travel long distances or wait for days to access specialised care for their children.

The causes of this crisis are deeply rooted. Low salaries often do not cover the cost of living, especially in urban centres where expenses are high. Many nurses report working long hours under stressful conditions, with limited access to professional development or specialised training. Career advancement opportunities are scarce, and recognition for their critical work is often lacking. These factors combine to create a sense of frustration and stagnation, pushing even the most dedicated nurses to seek better opportunities abroad.

Despite these challenges, there are signs of hope. Two hospitals: the Kathmandu Institute of Child Health's KIOCH-Damak Children's Hospital in Jhapa and the soon-to-open KIOCH-Kathmandu Children's Hospital are taking concrete steps to retain paediatric nurses. KIOCH-Damak, a 50-bed facility, offers higher salaries than many other hospitals in Nepal, giving nurses a reason to stay and support their families without going abroad. The hospital provides a supportive work environment, modern equipment, manageable shift schedules, and opportunities for professional growth.

KIOCH-Kathmandu is building on this model, actively recruiting nurses and designing a workplace focused on job satisfaction, collaboration, and advanced training. By investing in their staff's well-being and professional growth, these hospitals are creating environments where nurses feel respected and motivated to stay.

These hospitals serve a combined catchment area of over two million people, including 900,000 children. While they cannot solve Nepal's nationwide shortage alone, their approach offers a blueprint for the country. By valuing nurses through better pay, supportive environments, and career development, they show that it is possible to stem the brain drain.

The government and health care leaders must take these lessons to heart. Retaining paediatric nurses requires more than just higher salaries; it demands a comprehensive strategy that includes investment in training, improved working conditions, and opportunities for advancement. Policymakers should prioritise funding for paediatric nursing education, expand access to specialised training programmes, and develop clear career pathways that reward skill and dedication. Hospitals across Nepal must strive to create supportive, respectful workplaces where nurses are empowered to provide the best possible care.

The stakes could not be higher. Every nurse lost to migration is a blow to Nepal's healthcare system and the children who depend on it. By taking bold action now, investing in nurses, supporting their growth, and valuing their contributions, Nepal can protect its most vulnerable citizens and secure a brighter, healthier future for the next generation.

KC is a public health scholar with a deep interest in children's well-being