Nursing Shortage in Pakistan – Human Resource Management in Health Systems
Introduction to Human Resources for Health: Human resource management is a significant pillar of the health system that is responsible for any country’s most important asset: its people. Human resource management accounts for 70 to 80 percent of a country’s 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 the community by providing excellent services.
(1) Significance of Nurses in Human Resources for Health (HRH): 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 and hence the outcomes are costly and below expectations. We poorly prepare these Hospitals are poorly prepared 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 of managing a patient with multiple chronic illnesses. As a result, the number of chronically ill people landing in tertiary-care hospitals continues 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 reforms like 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 notes: “Shortage of nursing is a problem which undermines the effectiveness of the health system and needs to be solved. Until and unless 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) Setting the curriculum for the education of nurses, midwives, Lady Health Visitors (LHVs) and nursing auxiliaries
2) Inspection of educational institutions for approval based on established standards
3) To provide registration (license) for practice
4) Maintaining standards of education and practice
5) To work closely with the provincial Nursing Examination Boards (NEBs)
6) Playing an advisory role for the overall benefit of nurses, midwives, LHVs and nursing auxiliaries in the country
7) Maintaining an advisory role for the federal and provincial government regarding nursing education and nursing services
8) Communicating policy decisions regarding nursing education and the welfare of nurses, taken in council meetings, to governments, nursing institutions, NEBs and Armed Forces Nursing Services (AFNS) for implementation
9) Prescribing penalties for fraudulent registration by intention of pretense, and removes persons from the Register for professional misconduct.(2)
The analysis of these functions has been dealt with later in the paper.
Global and Regional Nursing Shortage: Shortage of nursing 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 in improving 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 by WHO in 2006)
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 to 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 nurse‐patient ratio is approximately 1:50 whereas PNC’s 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 the 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) by2015. Pakistan has a shortage of nurses, further exacerbated by a misdistribution across provinces. This shortage is particularly pronounced in Sindh, where there may not be adequate nurses and midwives. In contrast, Khyber Pakhtunkhwa has the highest number of nursing staff (7).
Causes of Nursing Shortage: Pakistan is not producing adequate number of nurses required to meet the needs of the growing population. Underproduction however, is not the only reason of a 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 a majority of war hit areas of the country, inferior status of nurses in society, insufficient number of quality nursing education institutes, feminist perception of nurses 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).
Way forward after devolution: In Pakistan, melancholy has grown about the impact 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 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 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 a way of augmenting nurse education in the Philippines(10). In 2004, the Philippines reported overall transfer of funds of about US$ 8.5billion, representing 10% of the country’s 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 hailing 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 employee’s training qualifications. Inspecting a nurse’s registration prevents unregistered nurses (who have not graduated from an institute) and those with deceptive credentials from obtaining service jobs.
In 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: Kenya’s experience of vacant rural posts is similar in many lower and middle income countries. 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 adopted a versatile approach in 2006. 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 travelling all the way 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 for the salary discrepancy of those not working in the metropolitan(14).
Rwanda: The pay-for-performance system in Rwanda had the maximum outcome on 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).
• Which countries are nurses migrating to? There is a need to research on where are the nursing graduates migrating. Moreover, what are the factors which compel them to migrate?
• What proportion of nurses is going to health related employment or education in other countries? Is it contributing to health anyway or is it just for VISA purpose? There has been a trend to educate females as graduates in nursing to attract marriage proposals from foreign countries. There is a 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 national data 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? Although Pakistan’s 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 a greater number of human resources and generate foreign exchange, but not at 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.
• How can revival of Human Resources for Health (HRH) address the issue in local context? According to the National Health Policy of 2009, there were explicit guidelines to revive Human Resources Management in the Ministry of Health. There were recommendations to develop national nursing policies that would standardize the nursing education and nursing practices all over the country. Unfortunately, that document is merely 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 need to 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 an emphasis 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 produce community 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 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 etc.
• Need to promote RESEARCH: It has been proven that research promotes education standards as well as brings changes for the betterment of clinical practice. Development of a national journal of nursing is a vital need of Pakistan. This can become a platform for sharing 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 a 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 towards production 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.
• Need to provide standardized incentives: As it is proven throughout the world that financial 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 for developing 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 cannot be implemented.
Equity, effectiveness, efficiency and accessibility can be achieved by empowering human resource for health departments.
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About the Author: Hussain Maqbool Ahmed Khuwaja is a student at AKU, Pakistan, studying MSc Health Policy and Management. He graduated BScN from AKU School of Nursing and worked in AKUH for 2 years as registered nurse. He wishes to work for Research and Development, Policy Analysis and Public Health Management in future. He can be reached at [email protected]
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