Nursing Shortage in Pakistan

7/29/2019 Nursing Shortage in Pakistan

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Hussain Maqbool Ahmed KhuwajaHealth Policy and Management, Year I

HPM12003Comparative Organization in Health Systems

Nursing Shortage in PakistanHuman Resource

Management in Health SystemsAga Khan University

Department of Community Health SciencesDr. Yousuf MemonDr. Suleman Otho


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H u s s a i n M a q b o o l A h m e d K h u w a j a ( H P M 1 2 0 0 3 ) Page 2

Nursing Shortage in Pakistan Human Resource Management in Health Systems 2012

Index

1.

Introduction to Human Resources for Health 3

2. Significance of Nurses in Human Resources for Health 33. Pakistan Nursing Council and its core functions 44. Global and Regional Nursing Shortage 45. Nursing Shortage in Pakistan 56. Causes of Nursing Shortage 57. SWOT analysis of Nursing in Pakistan 68. Way forward after Devolution 89. Comparison with Developing Countries 810.Research Gaps 1111.Recommendations 1212.References 14

Acknowledgements:

I would like to acknowledge Dr. Suleman Otho, Dr. Yousuf Memon, Dr. Yasmin Amarsi, Dr.

Rozina Karamaliani, Dr. Rafat Jan, Dr. Khurshid Khowaja, Miss Khairunissa Ajani and FHS

library.


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Introduction to Human Resources for Health:

Human resource management is a significant health systems pillar that is responsible for

any countrys most important asset: its people. HRM accounts for 70 to 80 percent of a countrys

health budget. When countries invest in people wisely, the result is a satisfied and motivated

workforce that delivers high-quality health services and a country that meets its health

objectives, and contributes to its community by providing excellent services. (1)

Significance of Nurses in Human Resources for Health:

In Pakistan, emergency departments of tertiary hospitals are used, instead of innovative

ambulatory and community-based models of care, to manage the effects of chronic illness, with

costly and poor outcomes. We poorly prepare these hospitals to manage such complex patients -

with insufficient personnel and ineffective technology. We produce an inadequate primary care

workforce and ask them to practice in settings that are incapable to manage the care of the

patient with multiple chronic illnesses. As a result, the numbers of chronically ill people landing


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in the tertiary hospitals continue to rise. This doubles the demand of the health workforce in

developing countries like Pakistan that is still in a trap of fatal communicable infectious diseases.

Nursing has put into practice innovative models of care that promote the goals of policymakers

for health reform: expanding access, improving quality and safety, and reducing costs. Extending

these models of care to the general public will be difficult without action to strengthen the future

nurse workforce. (2) Buchan has noted:

Nursing shortages are a health system problem, which undermines health system

effectiveness and requires health system solutions. Until this is understood, and

we make better use of the available evidence, we are doomed to endlessly repeat a

cycle of inadequate, uncoordinated, obsolete and often inappropriate policy

responses (3)

Pakistan Nursing Council (PNC) and its core functions:

The PNC is a sovereign, regulatory body constituted under the Pakistan Nursing Council

Act (revised in 1973) and empowered to register (license) Nurses, Midwives, Lady Health

Visitors (LHVs) and Nursing Auxiliaries to practice in Pakistan. Core functions of PNC are: 1)

PNC sets the curriculum for the education of nurses, midwives, Lady Health Visitors (LHVs)

and nursing auxiliaries; 2) PNC inspects educational institutions for approval based on

established standards; 3) PNC provides registration (license) to practice; 4) PNC maintains

standards of education and practice; 5) PNC works closely with Provincial Nursing Examination

Boards (NEBs); 6) PNC plays an advisory role for the overall benefit of nurses, midwives, LHVs

and nursing auxiliaries in the country; 7) PNC maintains an advisory role for the federal and

provincial government regarding nursing education and nursing services; 8) PNC communicates

policy decisions regarding nursing education and the welfare of nurses, taken in council

meetings, to governments, nursing institutions, NEBs and Armed Forces Nursing Services


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(AFNS) for implementation; and 9) PNC prescribes penalties for fraudulent registration by

intention of pretense, and removes persons from the Register for professional misconduct. (2)

The analysis of these functions is done later in the paper.

Global and Regional Nursing Shortage:

The nursing shortage is not just a governmental challenge or a topic for financial

analysis; it has a catastrophic impact on health care. Failure to deal with a nursing shortage be

it local, regional, national or global will lead to failure to improve health services. The World

Health Organization (WHO) estimates that the world needs to increase the number of health

workers by more than four million to achieve the global health goal in 2015 set by the

Millennium Development Goals (MDGs). Ultimately, the demand for nurses is growing as a

fundamental part of the overall health system to provide quality health care. (4, 5)

(Nurse:population ratio (nurse per 1000 population)min, max and average by WHO region. Source: Buchan and

Aiken, based on analysis of data in WHO 2006)


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Nursing Shortage in Pakistan:

In Pakistan, the coexistence of nurse shortage in the domestic market and outflow of

nurses to international markets is not unusual. Distinctively these migrant nurses are moving

towards gulf countries; look for better employment opportunities. At the same time, novice

nurses are needed to fill the gap between supply and demand in the domestic markets.

The existing nursepatient ratio is approximately 1:50, whereas PNCs prescribed ratio is

1:10 in general areas and 2:1 in specialized areas. A government notification hints that Pakistan

lacks 60,000 nurses. In 2009, there were 47,200 nurses on the register, including those in the

private sector; Lady Health Visitors (LHVs) numbered 4,752 and midwives 3,162. (2) PNC

estimates the 2008 nursing professionals to population ratio of 1: 3568 for nurses and 1: 54,276

for LHVs. The nurse: physician ration was 1: 2.5. (6) Moreover, Pakistan has been categorized

as one of 57 countries that are facing an HRH crisis, below the threshold level defined by WHO

to deliver the essential health interventions required reaching the Millennium Development

Goals (MDGs) by 2015. Pakistan has a shortage of nurses, further exacerbated by misdistribution

across provinces. This shortage is particularly pronounced in Sindh, where they may not be

adequate nurses and midwives. In contrast, Khyber Pakhtunkhwa has the highest numbers of

nursing staff. (7)

Causes of Nursing Shortage:

Pakistan is not producing the adequate number of nurses required to meet the needs of

growing population. But underproduction is not the only reason of nursing shortage in Pakistan.

There has been a significant brain drain to gulf countries. The indirect causes of nursing shortage

in Pakistan are social unrest in majority of war hit areas of country, inferior status of nurses in

society, insufficient number of quality nursing education institutes, feminist perception of nurses


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as females only, lack of career advancement in nursing profession, lack of continuous nursing

education, presentation of unethical image of nurses in electronic media, lack of law

implementation on sexual harassment, lack of retention policies, lack of incentives for distant

placements, lack of law implementation on horizontal and vertical bullying, lack of monetary

incentives, and poor working conditions in most of the public as well as private hospitals. (2, 6,

7)

SWOT analysis of Nursing in Pakistan:

STRENGHTS:

Nursing Act 1973(comprehensive)

Licensing examination initiated in2011.

Faculty development throughenrollment in MScN

Religious history for profession(Rufaida)

National Health Policy 2009guidelines

Plan to initiate Bachelors ofMidwifery.

WEAKNESSES:

No active regulatory activity.

No registration of LPN and NA asyet.

No research journal

No retention initiative

No representation in Legislation

No local literature

Historically headed by physicians

No action on sexual harassmentcases

Fake oversees employment agentsall over Pakistan

No inspection of workinghours/person/week

50 patients/nurse for 12 hrs

OPPORTUNITIES:

Specializations in Nursing

Local textbooks by MSc and PhDgraduates

National journal of NursingResearch

PhD in Nursing programs

Rapid Response Teams in DisasterManagement

Trauma and Mobile health

Ageing Systematic HomeHealth

THREATS:

International migration

Oversees labor problems

Globalization more influx ofpatients from costly countries

Increased workload on physiciansand surgeons

Less focus on preventionprograms

Inequalities among rural areas


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Way forward after Devolution:

In Pakistan, melancholy has grown about the impact that the reallocation of roles and

responsibilities has had on the health workforce and its management. The different concerns

have been affected by unprepared decentralization processes. The ideal recommendations

regarding the key concerns that national and international agencies should give prompt attention

to are (1) defining the essential human resource policy, planning and management skills for

national human resource managers who now work in a decentralized environment, and

developing training programs to equip them with such skills; (2) supporting research that focuses

on improving the knowledge base of how decentralization has impacted on workforce equity;

and (3) identifying factors that empower health workforce motivation and performance after

decentralization, and analyzing the most cost-effective best practices to improve and maintain

them. (8)

Comparison with Developing Countries:

Philippine:

Philippine policymakers have initiated innovative programs in nursing care delivery with

two goals: (1) to draw upon the pool of nurses that are unable to find work domestically or

abroad and (2) to utilize these nurses skills in delivering healthcare to underserved and rural

areas of the Philippines. The Nurses Assigned to Rural Service program, or NARS, was

described as a stop-gap solution to unemployment through deployment of nurses to rural,

underserved areas for a six month commitment. (9) In addition to transnational exchange of

support, nursing administrators and educators have sought to engage the expertise of Filipinos

residing abroad through reintegration programs. These initiatives would facilitate the return

and temporary residence of Philippine-born or Philippine-descent nurses at educational


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institutions, where they would provide training support and workforce development. Nurse

reintegration programs were discussed as ways to not only encourage foreign-residing Filipino

nurses to give back to their home country, but also as way to augment nurse education in the

Philippines. (10) In 2004, the Philippines reported overall transfer of funds of about US$ 8.5

billion, representing 10% of the countrys GDP. At the same time the government is planning to

attract its migrants back to home after a span of service abroad. Many benefits are granted to

return expatriates. The Philippines experiment has had encouraging results and is seen by some

developing countries as a role model. (11)

South Africa:

Through distance education, the School of Public Health of the University of the

Western Cape, South Africa, has provided access to master's level public health education for

health professionals from more than 20 African countries while they remain in post. Since 2000,

concentration has improved tremendously to a state where four times more applications are

received than can be accommodated. This home-based program remains insightful to the needs

of the target learners while engaging them in high-quality learning practical in their own work

contexts. (12)

Uganda:

Computerized human resources information systems (HRIS) enable countries to collect,

maintain, and analyze health workforce data. The electronic HRIS added significant value to the

(Uganda Nurses and Midwives Council) UNMC. Electronic records are easier to locate and

renew, facilitating Council team to more practically confirm a potential employees training

qualifications. Inspecting a nurses registration prevents unregistered nurses (who have not

graduated from an institute) and those with deceptive credentials from obtaining service jobs. In


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addition, the system provides a way to ensure that nurses and midwives have completed the

continuous professional development courses required to maintain licensure. This verification

process enables the UNMC to fulfill its social contract of maintaining a standard of nursing care,

in this manner gaining public assurance in the health system. (13)

Kenya:

Kenyas experience ofvacant rural posts is similar in many Lower and Middle Income

Countries (LMIC). Despite the political determination to employ more health workers, Kenya

had inadequate funds to expand the workforce in short-staffed rural areas. To tackle this crisis,

Kenya in 2006 adopted a versatile approach. First, the Ministry of Health used external donor

resources to commence the Emergency Hiring Program. This external funding stream provided

three-year bonds to health workers, instructing that they focus on less-served regions. The

Ministry of Health administered these funds and hired the workers. Second, contrasting with the

earlier hiring practice, applicants from rural regions were interviewed in their home town rather

than be required to travel to Nairobi. Third, for workers in rural areas, the Ministry of Health has

executed hardship allowances, accommodation grants and two sessions of earned leave. The goal

of these inducements was to compensate the salary discrepancy of those not working in

metropolitan. (14)

Rwanda:

The pay-for-performance system in Rwanda had the maximum outcome on those

services that had the utmost compensation rates and needed the least endeavor from nurses and

community midwives. Pay-for-performance monetary performance incentives can improve both

the value and quality of reproductive health services, and could be a constructive intervention to

hasten improvement towards Millennium Development Goals. (15)


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Research Gaps:

Which countries are nurses migrating to? There is a need to research on where are thenursing graduates migrating. Moreover, what are the factors that enforce those nurses to

migrate?

What proportion of nurses is going to health related employment or education in othercountries? Is it contributing to health anyway or just VISA purpose? There has been

trendy to educate females with graduate education in nursing so that their marriage

proposals in foreign countries become easy. There is need to evaluate whether the

number of nurses migrating to other countries of the world contribute to the profession or

not.

What harms more; internal or external migration? As there is no provincial or nationaldata available on the number of nurses registered and the number of nurses practicing in

hospitals, it is difficult to evaluate the kind of migration that is occurring more. Internal

migration from rural to urban is more destructive for a developing country like Pakistan

as most of the population lives in rural areas of the country.

What is the social and economic impact of the flow out of the country? AlthoughPakistans economy has a larger share of foreign exchange earned by oversees

employees, it does not mean we shall exceedingly depend on this portion of foreign

exchange. This is no doubt an opportunity to produce more number of human resources

and generate foreign exchange, but not on the cost of lives of citizens. Research must be

done on the economic and social losses incurred by Pakistan due to lack of Human

Resources for Health and particularly nurses.


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How can revival of Human Resources for Health (HRH) address the issue in localcontext? According to National Health Policy 2009, there were explicit guidelines to

revive Human Resources Management in Ministry of Health. There were

recommendations to develop national nursing policies that would standardize the nursing

education and nursing practice all over the country. Unfortunately, that document has

merely been a piece of paper only.

Recommendations:

A number of recommendations could be made after comparing the health systems

loopholes with other developing countries. A few workable solutions are:

Shifting the paradigm from physician supremacy to nursing leadership: There is a needto promote a culture of nursing leadership both inside and outside hospital environments.

Production of nurses as well as retention of current workforce: There has been anemphasis on production of more and more doctors since independence 1947. There has

been an emphasis on cure and the significance of care has been neglected. There is a need

to value the balance between cure and care i.e. the ratio of nurses to doctors must not be

imbalances. Reaching towards the international ratio would be an ideal and rather

unrealistic goal. Planning to produce adequate nursing workforce that would at least

balance the ratio would be a short term achievable goal. For that urgent efforts to

construct registered nursing institutes and promote nursing education are required.

Need to promote all tiers of nursing: Currently the emphasis has been to producecommunity midwives and registered nurses. To meet the extreme shortage, there is an

urgent need to promote licensing of practical nurses and nursing auxiliaries. Community

midwives have known to produce better outcomes in Pakistan as well as other


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neighboring countries. But there is a lack of ownership to these community midwives.

There must be systemic registration (licensure) of lady health workers and community

midwives.

Need to bring about specializations in Nursing: Currently three year diploma program,four year generic baccalaureate and two years post baccalaureate generic masters

program are being taught in registered institutes across the country. There is a need to

introduce specialization certification programs like special education diploma, public

health diploma, mental health diploma, geriatric care diploma, and etc.

Need to promote RESEARCH: It has been proven that research promotes education

standards as well as brings changes for betterment in clinical practice. Development of a

national journal of nursing is vital need of Pakistan. This can become a platform to share

advancements in nursing education, management, leadership and clinical practice. Hence,

the causes of nursing shortage and solutions to this ongoing problem could be

implemented in local context realistically. Moreover, there is a need to develop local

literature in nursing education. The doctoral graduates of Pakistan must work

collaboratively to develop nursing textbooks in local context. Lessons can be learnt from

India to develop nursing literature that enables students to comprehend the problems

faced by the country.

Representation in Policy making: There is a huge room for policy making towardsproduction and retention of all cadres of nursing. These policies should not be made

isolating the major stakeholders i.e. nursing workforce and nursing leadership. Even PNC

should not be lead by a non-nursing person. The representation of nurses in policy

making is essential.


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Need to provide standardized incentives: As it is proven throughout the world thatfinancial as well as non-financial incentives contribute to better outcomes. Some of

possible and realistic incentives are: Pay for Performance i.e. providing extra incentives

for night shifts, distant placements, high acuity areas, medical coverage, on-call

incentives, and flexible working hours. These incentives have proven to produce good

outcomes in developing countries.

Need to develop Human Resource for Health (HRH) departments in all provinces:Without making a department that focuses on the human resource management, the

solutions to workforce problems could not be implemented. Equity, effectiveness,

efficiency and accessibility can be achieved by empowering human resource for health

departments.

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Nursing Shortage in Pakistan

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