The Heart of Healthcare Systems

Every one of us has to see a doctor many a time in our life. However, when this needs become acute, we need another person besides a good doctor and that is a nurse, also called sister or staff. They are the main pillar of the whole edifice of healthcare in a society. And, to pay gratitude and show our reverence to nurses, International Nurses Day is celebrated around the world every year on May 12, the anniversary of Florence Nightingale’s birth. This observation calls our attention to the fact that encouraging and supporting nurses is indispensable to making an optimal use of education, training and skills the nurses are imparted. And, this encouragement and support can be given to them only by solving the problems they are mired in. These include excessive workload, violence at workplace, low wages, long working hours and other workplace risks. Owing to all these problems, the paucity of nursing staff is the most daunting problem today’s world is faced with. In 2013, the International Council of Nurses Workforce Forum found that most industrialized countries are, or will be imminently, facing a shortage of nurses due to the increased demand for healthcare. In addition, a survey performed by the World Health Organization (WHO) found that 77 percent of developed countries are facing a nursing staff shortage. This universal shortage adversely impacts not only the healthcare systems and the patients, but also the nurses themselves; with an increase in the number of patients they have to attend, workload increases manifold and to cope with this situation, they are made to work for late hours which creates in them depression and dissatisfaction with their work.

Studies suggest that long working hours lead to personal conflicts among nurses, perpetuation of agony for patients, clashes, dissatisfaction with the work and lethargy. A recent study conducted in the United States, Canada, Great Britain, Scotland and Germany has revealed that as many as 44 percent nurse have no job satisfaction while 22 percent are willing to leave the profession. The results further show that workplace pressure undermines nurses’ morale, causes job dissatisfaction in them and saps their resolve to work with their organization which often leads them to leaving the job. Moreover, when they are made to attend more patients, their responsiveness decreases, their diligence to improve a patient’s condition by according due care to him declines due to which they, knowingly or unknowingly, administer wrong medicine which can prove fatal to patients under their care. So, it is indispensable that the paucity of nurses be made up for. But, here arises a question: what number of nurses is sufficient to fill this gap?

In this regard, the WHO has set two standards. According to one standard, there should be at least 50 nurses for a 10,000 population whereas the second sets this number to 4 nurses with one doctor. When we see, keeping in view these standards, the number of nurses in Pakistan, a crisis situation comes before us. A brief analysis of the figures reported in the Population and Housing Census of Pakistan 2017, Economic Survey of Pakistan 2016-17, Punjab Development Statistics 2016, Development Statistics of Sindh 2016, Development Statistics of Khyber Pakhtunkhwa 2016 and Development Statistics of Balochistan 2016, as well as of the figures reported by Pakistan Medical and Dental Council reveals that, at present, the number of nurses in Pakistan should be 10,38,873, but we have only 99,208 of them which means we are facing a shortage of 9,39,645 nurses. And if we see the situation in terms of percentage, the paucity comes out to be 90.4 percent.

And, on the second standard, the number of MBBS doctors, specialists and foreign-qualified doctors, as on 28 February 2018, was 4,23,160 and the number of nurses needed to assist them was 16,92,640. Hence, on this standard, we are still in want of 15,93,412 nurses – 94.1 percent in terms of percentage points. Furthermore, if we analyze the situation regarding the availability of nurses in terms of population, there were, on average, only 5 nurses available for 10,000 population, in 2016 whereas that availability in terms of providing assistance to the doctors was only 0.51 per doctor. On the standards of WHO, Sindh comes out to be the province having the acutest shortage of them as it has 99.3 percent fewer nurses and 99.7 percent fewer doctors. Moreover, Sindh, again, is the worst province in terms of availability of nurses as the ratio of their availability till 2015 was only 0.20 per doctor and 0.35 per 10,000 population.

The first among the foremost reasons for this state of affairs in Pakistan is the limited number of nursing institutions. At present, there are only 128 nursing institutions, with a capacity of 9,468 students, which are offering general nursing diplomas accredited by Pakistan Nursing Council (PNC). Likewise, the number of those offering one-year post-basic specialist diploma is only 39 whereas degree-awarding institutions are 62 having a capacity of 3333 students. In addition, the number of institution offering licensed practical nurse course is only 18 and they can provide training only to 505 people. Hence, the total number of PNC-accredited nursing education institutions is 247 having a capacity to train 13,306 students. And, in a country where population grew, on average, by 39,60,000 people every year between 1998 and 2017, and where only 9,468 male and female students enrol themselves for nursing education, and that too of a diploma level, every year what could be the possible ways to make up for the chronically-acute deficiency of nurses?

There are two possible solutions to this issue. First is to increase the number of institutes providing nursing education and also the number of seats they offer. Moreover, facilities and privileges should be provided to attract more and more students, besides efforts to enhance the prestige of this field. In this regard, Ms Safoora Safdar, a nurse currently performing her duties at the Shaikh Zayed Medical Complex Lahore, opines that when she joined this profession, nurses were not accorded such honour and respect as they enjoy today and it is because that a number of nurses have acquired higher education that has been key to improving their life as well as status in the society. She said, “Nurses are now getting educated at MS and PhD levels and that has helped them garner more respect in the society.” However, she lamented, “Although higher education proves rewarding in professional life, yet that does not translate into financial benefits because no allowance is paid to nurses so as to make them excel in their professional education. Moreover, if a nurse somehow succeeds in acquiring higher professional education, she hardly gets promoted owing, mainly, to lack of proper service structure.”


The other possible solution could be to attract nurses from other countries to work in Pakistan. That, too, doesn’t seem feasible at present-when we cannot solve the problem of the indigenous nurses, then how on earth will we be able to solve those of the foreign ones?

Keeping in view the ground realities, the only pragmatic solution is to create more and more educational opportunities for them besides restructuring the curriculum and building it on modern lines. In addition, providing more perks and privileges to those already in this field is also important. Such measures will be instrumental to not only meeting the local requirements of nursing staff but also to exporting this human resource to the international market. If we pay due attention to this sector, we will be able to earn huge foreign exchange because all countries, whether developed or the developing ones, need nurses. We can have a fair idea of the situation from the figures released by the US Bureau of Labor Statistics which suggest that more than 5,00,000 registered nurses in America will retire by 2022, and the country will require 1.1 million new nurses for expansion and replacement of the retirees and to avoid a nursing shortage; as the US nursing sector annually creates 100,000 new jobs – far more than those created by any other sector. This need is largely met from international market and at least 15 percent of nurses currently working in the United States are from other countries. As per the findings published by the Institute for Immigration Research of George Mason University revealed that in 2015, immigrant registered nurses reported a higher median salary ($74,500) than native-born US citizens who are registered nurses ($65,000). Similarly, the WHO reports that 77 percent developing countries are faced with a shortage of nurses and almost all of those are relying on nurses coming from other countries to ameliorate the situation. The Philippines is the biggest source country of nursing exports who send remittances to the tune of US$ 800 million annually back home. Internationally, the immigrant nurses are acknowledged as an important partner in economic development with the remittances they send to their home countries. These remittances are considered an important source of earning more income, ergo acquiring economic stability, at individual, family and community levels. These amounts help improve access to food, housing and healthcare facilities, thus providing relief to the overburdened health infrastructures. This significance of foreign remittances is especially visible in low- and middle-income countries where they play a key role in poverty alleviation efforts.

A number of domestic push and foreign pull factors are involved in international nurse migration. External pull comes into play due to globalization and free market. Since professional training, handsome salary packages, perks and better lifestyles are involved as internal push factors, their lack essentially makes way for the push factor.

Knowing authentic facts and figures on the number of Pakistani nurses working abroad is always a herculean task as the only source available is the data maintained by the Bureau of Emigration & Overseas Employment, Government Pakistan, according to which from 1971 up to March 2018, as many as 8,382 nurses from Pakistan have migrated abroad on a work visa. In 2017, only 293 nurses went abroad to work-indeed, a very low number. While commenting on very limited number of nurses opting for going abroad, Sister Anjum said, “In the past, nurses have been going abroad mainly because they were given meagre salaries here in Pakistan. However, situation has improved a lot and they are being paid reasonable salaries owing to which they do not prefer going abroad. And, those who go do so mostly to earn higher education in this field.” When asked whether the curriculum being taught and training being imparted to our nurses are not compatible to international standards, she said, “Nursing education in Pakistan is undergoing evolution and our girls are even acquiring MPhil and PhD degrees. The curriculum and training here in Pakistan is not at all below the international standards. Nowadays, a nurse has to study as much as a doctor has to.”

Despite the fact that nurses continue to provide better healthcare facilities to the people all through their lives, and people too keep on demanding more and more from them, it’s a sad reality that their tremendous services often do not get due recognition and appreciation and people don’t stop even from manhandling and harassing them.

Do you have even a slight idea of how toilsome a nurse’s work is? know how much a nurse has to walk while performing her duties? As per a research published in the Journal of the Academy of Medical-Surgical Nurses of the United States, a nurse, on average, has to walk 4-5 miles during her twelve-hour-long duty every day in comparison to 2.5-3 miles of an average American.

Here in our hospitals, they have to work more but still people often complain that nurses do not behave well with the patient or his/her attendants as they don’t attend the patient despite repetitive requests and get enraged even on petty things. Sister Anjum agrees to this–to some extent though–and says that this happens in some situations but she blames the shortage of nursing staff for this. She says, “Our hospitals are overburdened and the number of nurses to attend them is extremely insufficient. When a nurse will have to attend 50-60 patients at a time, then it is all natural if she gets vexed or irritated. However, the fresh nurses coming into this profession are more qualified and more aware of its compulsions. So, their behaviours have also improved.”

The crux of the situation is that the number of nurses in Pakistan is extremely insufficient when compared with that of the patients. And, a research paper published the Journal of Pioneering Medical Sciences further corroborates this assertion as it suggests that the existing nurse-patient ratio in Pakistan is approximately 1:50 whereas the ratio prescribed by the Pakistan Nursing Council (PNC) is 1:10 in general areas and 1:2 in specialised areas. But, the on-ground situation is much different from that prescribed by the PNC. An international research proves that the higher the number of nurses, the lower the number of mortalities as in hospitals having better ratio of nurses, patients are provided better attention and they has a satisfaction that they are being properly treated. But, if we analyze the average number of nursing staff in our hospitals, the Economic Survey of Pakistan 2016-17 portrays a gloomy picture as according to the figures provided in it, the average number of nursing staff per hospital in 2016 was only 83. Amidst this state of affairs how easy, or difficult, will be the achieving of targets set under the Sustainable Development Goals, only the time will tell. However, one thing is certain: equitable access to quality healthcare facilities will remain an unfulfilled dream sans recruiting more and more trained nurses to this field.