In January this year, the President of Pakistan, Arif Alvi, announced that the government will spend 3.5 billion rupees on the nursing profession and produce 100,000 nurses in four years. He also said that 2019 will be declared the year of nursing in Pakistan. The president said that the government will create a university of nursing in Islamabad, and that the three-year nursing diploma programme will be abolished and replaced by a degree programme.
Somehow the president forgot to mention the importance of midwives in the promotion of maternal health and prevention of disease. He also did not explain how the country will achieve the target of producing such a large number of nurses in a country where primary and secondary schools are not functional and it is difficult to find matriculates for the on-going diploma and certificate programmes in nursing and community midwifery respectively.
It seems that the president and his advisers have no idea about the ground realities regarding education and training of nursing, midwifery and paramedics in the country. Nor have they any understanding of the role of specialist nurses in the existing healthcare system. They have a huge amount of funding but no fundamental understanding about the challenges of education in nursing and midwifery, nor of the ground realities regarding basic education of girls and boys who join these professions. They also appear to be unaware of the status of faculty at nursing and midwifery schools in Pakistan.
The president’s initiative to create a nursing university seems divorced from the reality on the ground and what needs to be done
At present, there are 82,000 nurses registered with the Pakistan Nursing Council (PNC). In the public sector, we have 23 schools of nursing in Sindh, 45 in Punjab, 10 in Khyber Pakhtunkhwa and five in Balochistan. We have less than 50 private nursing schools. About 28,000 midwives are registered with the PNC and we have 106 schools of midwifery in the public and private sector. The majority of the nurses are not well-trained because of the unavailability of trained faculty members in nursing schools in public and private sectors.
Most of these schools do not have proper buildings, teaching equipment, basic libraries, skills labs and qualified faculty members. In fact, there is no proper career structure for faculty members. Usually, a medical superintendent appoints his favourite nurse to a teaching school as tutor or principal to have an easier task without any clinical duties. At the same time, she becomes the in-charge of a certain number of nursing and midwifery pupils with the authority and power that comes with it. With the exception of a few public-sector schools of nursing and midwifery, the majority of the institutes have failed to produce skilled and professional nurses who can perform their duties with confidence and empathy. In some private-sector schools, training is better but the students have to pay a fee instead of getting stipends and are exploited by the owners of the hospital.
A study by Unicef Pakistan shows that 90 percent of certified midwives get certificates without performing a single normal delivery. They do not have the skill to conduct antenatal clinics nor are they trained to work as community midwives. A vast majority of midwifery schools do not have faculty, nor a structured training programme for students.
As a member of the admissions committee for nursing and midwifery schools, I have experienced the challenge in finding candidates fit for nursing and midwifery. The students confess that they passed grade 10 exams through cheating. Some of them even confess to having obtained the certificate after paying money to agents without appearing in exams. The education mafia is strong and active in different boards of secondary and intermediate education.
Pakistan needs more than 1,200,000 nurses and more than 300,000 midwives to provide basic and emergency nursing care to patients in general and maternity hospitals. We need specialist nurses in specialties such as neonatal care, medical/surgical intensive care, cardiac, renal dialysis, orthopaedics and ophthalmology units. In Sindh, there are 54,000 posts for nursing staff but only 3,700 nurses are working in public-sector hospitals.
The situation is not different in other provinces. Pakistan has failed to produce enough skilled and competent nurses and midwives to run our hospitals and healthcare system. Instead of addressing the grievous situation, it is remarkable that the president came up with the idea of a nursing university and degree programme when there is an acute shortage of human resource, basic facilities and infrastructure in existing schools of nursing all over the country.
It’s easy to spend millions on building, equipment, consultancy and vehicles for the blue-eyed incompetent vice chancellors, newly-appointed deans and faculty members. We have seen this kind of investment in medical colleges and their overnight conversion into medical universities during the Musharraf government. It was religiously followed by two consecutive democratic governments for the benefit of vested interest groups. Unfortunately, the new government and president have chosen the same path without understanding the issues related to nursing and midwifery training in Pakistan. The president should have had initiated a plan to improve the existing system to produce competent human resource to work in tertiary care hospitals, taluka headquarters, Rural Health Centres, Basic Health Units and community centres. The president’s proposed plan in this regard will only create a system with too many chiefs and not enough Indians.
Three-and-a-half billion rupees is a huge amount to change the whole structure of nursing in Pakistan. The president should form a task force comprising people who have an interest in patient care and the nursing profession and not in slogans, buildings, shopping and the posts of chancellors and their perks. The task force should address the following issues on emergency basis:
— There is a need to start a massive teachers’ training programme for the existing faculty in schools of nursing and midwifery across the country. A great number of dedicated teachers should be appointed from the present nursing staff on emergency basis and should be trained in teaching and clinical training in our nursing institutes. They should be paid well and must have an attractive career structure.
— All nursing and midwifery schools should be uplifted and refurbished in their existing buildings. Basic amenities such as classrooms with furniture, faculty rooms, principal’s offices, toilets for students and faculty, clean water and electricity should be available in these institutes. It is shameful to see that, with the exception of a few, most of the public-sector schools are in an abysmal state in all provinces.
— We need proper libraries, computer labs and skill development centres with enough staff to train students. A system should be developed for continuous medical education and training for faculty members.
— It is not possible to bring revolutionary changes in the education system of Pakistan. At present, the government has no plan to discipline secondary and higher secondary boards of examinations which will continue the system of examination based on cheating, while the students will continue to purchase Matric and Intermediate certificates for themselves. The task force should appoint young teachers in nursing institutes to teach newly selected pupils in basic subjects such as English, Urdu, basic mathematics and science to improve their foundation. This will help them to continue further education in the nursing profession.
— The task force should continue the three-year diploma course in nursing and two-year certificate course in community midwifery. This is the only way to attract matriculate girls in the nursing profession. They should be taught on a scientific basis, with extensive clinical teaching by trained tutors. The nursing and midwifery force is essential to run hospitals, and should be the backbone of the nursing care system in Pakistan. During their training they should become aware of different branches and specialisation subjects in nursing and midwifery. Their foundation should be strong, based on which they can further plan their career.
— The task force should establish a system wherein, after a diploma in nursing and one or two years of ward experience, nurses should be able to do two-year degree programme in different specialities, such as advanced general nursing, neonatology, intensive care, etc. They should be facilitated to do Masters and PhD in nursing and midwifery. They should be able to choose different branches such as administration, teaching, research and hospital nursing. The post-graduate programmes can be organised in existing medical universities in major cities of Pakistan. There is no need of a nursing university for this purpose.
— The task force should be able to develop a career structure for nurses and midwives with the provision to progress in their field of interest. They should be well paid and their role recognised. This will be only possible when we produce skilled and competent nurses and midwives.
— Lastly, the task force should work for an independent, autonomous and responsible Pakistan Nursing Council/Pakistan Midwifery Council based on merit which can monitor nursing and midwifery professions and make sure that they will continue as regulatory bodies and will help the profession to grow.
The president’s initiative for the nursing and midwifery profession in the country is laudable but this kind of billion-rupee initiative is useless without proper objective planning. Half-hearted programmes for the benefit of vested interest groups will not survive and will not change or help the system.
The writer is ex-secretary general of Pakistan Medical Association. His team has translated more than 20 books on nursing and midwifery in Urdu
Published in Dawn, EOS, April 14th, 2019