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Hussain Maqbool Ahmed Khuwaja Health Policy and Management, Year I HPM12003 Comparative Organization in Health Systems Nursing Shortage in Pakistan Human Resource Management in Health Systems Aga Khan University Department of Community Health Sciences Dr. Yousuf Memon Dr. Suleman Otho

Nursing Shortage in Pakistan Human Resource Management in Health Systems

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Index

1. Introduction to Human Resources for Health 2. Significance of Nurses in Human Resources for Health 3. Pakistan Nursing Council and its core functions 4. Global and Regional Nursing Shortage 5. Nursing Shortage in Pakistan 6. Causes of Nursing Shortage 7. SWOT analysis of Nursing in Pakistan 8. Way forward after Devolution 9. Comparison with Developing Countries 10. Research Gaps 11. Recommendations 12. References

3 3 4 4 5 5 6 8 8 11 12 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 in 2011. Faculty development through enrollment in MScN Religious history for profession (Rufaida) National Health Policy 2009 guidelines Plan to initiate Bachelors of Midwifery.

WEAKNESSES:
No active regulatory activity. No registration of LPN and NA as yet. No research journal No retention initiative No representation in Legislation No local literature Historically headed by physicians No action on sexual harassment cases Fake oversees employment agents all over Pakistan No inspection of working hours/person/week 50 patients/nurse for 12 hrs

OPPORTUNITIES:
Specializations in Nursing Local textbooks by MSc and PhD graduates National journal of Nursing Research PhD in Nursing programs Rapid Response Teams in Disaster Management Trauma and Mobile health Ageing Systematic Home Health

THREATS:
International migration Oversees labor problems Globalization more influx of patients from costly countries Increased workload on physicians and surgeons Less focus on prevention programs 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 of vacant 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 the nursing 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 other countries? 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 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 Pakistans 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 local context? 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 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

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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 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.

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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 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-inaction.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).

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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.

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