7/29/2019 Nursing Shortage in Pakistan
1/15
qwertyuiopasdfghjklzxcvbnmqwerty
opasdfghjklzxcvbnmqwertyuiopasdfg
klzxcvbnmqwertyuiopasdfghjklzxcvb
nmqwertyuiopasdfghjklzxcvbnmqwe
yuiopasdfghjklzxcvbnmqwertyuiopa
dfghjklzxcvbnmqwertyuiopasdfghjklz
vbnmqwertyuiopasdfghjklzxcvbnmq
wertyuiopasdfghjklzxcvbnmqwertyu
pasdfghjklzxcvbnmqwertyuiopasdfgh
klzxcvbnmqwertyuiopasdfghjklzxcvbmqwertyuiopasdfghjklzxcvbnmqwer
uiopasdfghjklzxcvbnmqwertyuiopasd
ghjklzxcvbnmqwertyuiopasdfghjklzxvbnmqwertyuiopasdfghjklzxcvbnmrt
uiopasdfghjklzxcvbnmqwertyuiopasd
ghjklzxcvbnmqwertyuiopasdfghjklzx
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
7/29/2019 Nursing Shortage in Pakistan
2/15
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.
7/29/2019 Nursing Shortage in Pakistan
3/15
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 3
Nursing Shortage in Pakistan Human Resource Management in Health Systems 2012
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
7/29/2019 Nursing Shortage in Pakistan
4/15
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 4
Nursing Shortage in Pakistan Human Resource Management in Health Systems 2012
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
7/29/2019 Nursing Shortage in Pakistan
5/15
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 5
Nursing Shortage in Pakistan Human Resource Management in Health Systems 2012
(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)
7/29/2019 Nursing Shortage in Pakistan
6/15
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 6
Nursing Shortage in Pakistan Human Resource Management in Health Systems 2012
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
7/29/2019 Nursing Shortage in Pakistan
7/15
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 7
Nursing Shortage in Pakistan Human Resource Management in Health Systems 2012
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
7/29/2019 Nursing Shortage in Pakistan
8/15
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 8
Nursing Shortage in Pakistan Human Resource Management in Health Systems 2012
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
7/29/2019 Nursing Shortage in Pakistan
9/15
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 9
Nursing Shortage in Pakistan Human Resource Management in Health Systems 2012
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
7/29/2019 Nursing Shortage in Pakistan
10/15
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 10
Nursing Shortage in Pakistan Human Resource Management in Health Systems 2012
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)
7/29/2019 Nursing Shortage in Pakistan
11/15
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 11
Nursing Shortage in Pakistan Human Resource Management in Health Systems 2012
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.
7/29/2019 Nursing Shortage in Pakistan
12/15
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 12
Nursing Shortage in Pakistan Human Resource Management in Health Systems 2012
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
7/29/2019 Nursing Shortage in Pakistan
13/15
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 13
Nursing Shortage in Pakistan Human Resource Management in Health Systems 2012
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.
7/29/2019 Nursing Shortage in Pakistan
14/15
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 14
Nursing Shortage in Pakistan Human Resource Management in Health Systems 2012
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.
References:
1. Sylvia V et al. Health Systems in Action: An eHandbook for Leaders and Managers.:
Cambridge; 2010 [cited. Available from: http://www.msh.org/resource-center/health-systems-in-
action.cfm.
2. Judith Oulton BH. Review of the Nursing Crisis in Bangladesh, India, Nepal and
Pakistan. Journal [serial on the Internet]. 2009.
3. Buchan J, Aiken L. Solving nursing shortages: a common priority. Journal of Clinical
Nursing. 2008;17(24):3262-8.
4. Kingma M. Nurses on the move: a global overview. Health Services Research.
2007;42(3p2):1281-98.
5. Oulton JA. The global nursing shortage: An overview of issues and actions. Policy,
Politics, & Nursing Practice. 2006;7(3 suppl):34S-9S.
6. Khowaja K. Healthcare systems and care delivery in Pakistan. Journal of Nursing
Administration. 2009;39(6):263-5.7. Hafeez A, Khan Z, Bile KM, Jooma R, Sheikh M. Pakistan human resources for health
assessment. Health.5.
8. Kolehmainen-Aitken RL. Decentralization's impact on the health workforce: Perspectives
of managers, workers and national leaders. Human Resources for Health. 2004;2(5):1-11.
9. Asis MMB. The global financial crisis and international labor migration in the
Philippines. paper published on www smc org ph (forthcoming).
7/29/2019 Nursing Shortage in Pakistan
15/15
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 15
Nursing Shortage in Pakistan Human Resource Management in Health Systems 2012
10. Lorenzo FME, GalvezTan J, Icamina K, Javier L. Nurse migration from a source
country perspective: Philippine country case study. Health Services Research.
2007;42(3p2):1406-18.
11. Kirigia J, Akpa Gbary LM, Nyoni J, Seddoh A. The cost of health professionals' brain
drain in Kenya. BMC health services research. 2006;6(1):89.
12. Alexander L, Igumbor EU, Sanders D. Building capacity without disrupting health
services: public health education for Africa through distance learning. Hum Resour Health.
2009;7:28.
13. Spero JC, McQuide PA, Matte R. Tracking and monitoring the health workforce: a new
human resources information system (HRIS) in Uganda. Human Resources for Health.9(1):6.
14. Adano U. The health worker recruitment and deployment process in Kenya: an
emergency hiring program. Human Resources for Health. 2008;6(1):19.
15. Basinga P, Gertler PJ, Binagwaho A, Soucat ALB, Sturdy J, Vermeersch CMJ. Effect on
maternal and child health services in Rwanda of payment to primary health-care providers for
performance: an impact evaluation. The Lancet.377(9775):1421-8.