Health_Human_Resource by Nur Center for Research and Policy

TABLE OF CONTENT Acronyms Glossary of Terms Key Words Acknowledgements Executive Summary SECTION ONE: STRATEGIC FRAMEWORK 1.1 1.2 1.3 1.4 1.5 1.6

INTRODUCTION METHODOLOGY CONSULTANTS COMMENTS ON THE TERMS OF REFERENCE RATIONAL SUMMARY OF THE CONCEPTUAL FRAMEWORK BACKGROUND CONTEXT

02 02 04 04 06 08

SECTION TWO: HEALTH HUMAN RESOURCE FRAMEWORK

2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8 2. 9 2.10 2.11 2.12 2.13

13 14 14 14 15 15 17 18 19 22 22 27 29

GENERAL OVERVIEW PRODUCTION AND RETENTION OF HEALTH CARE PROVIDERS EDUCATION AND TRAINING OF HEALTH CARE PROVIDERS HEALTH SECTOR STAFFING IN PUNJAB BASIC PAY SCALES KEY HUMAN RESOURCE FUNCTIONS MANAGEMENT OF HEALTH STAFF GENERAL OVERVIEW OF DOCTORS MEDICAL COLLEGES GENERAL OVERVIEW FOR NURSES, LHVs AND MIDWIVES NURSING EDUCATION GENERAL OVERVIEW FOR LADY HEALTH WORKERS GENERAL OVERVIEW FOR PARAMEDICS

SECTION THREE: HEALTH HUMAN RESOURCE PLANNING AND MANAGEMENT: Key Challenges and Strategies

3.1 3.2 3.3

33 34 36

GENERAL OVERVIEW ADDRESSING HUMAN RESOURCE PLANNING AND MANAGEMENT PROPOSED KEY STRATEGIES – HUMAN RESOURCE FUNCTIONS

3.4

DEVELOPMENT OF A HUMAN RESOURCE DEPARTMENT

SECTION FOUR: HEALTH HUMAN RESOURCE DEVELOPMENT: Key Challenges and Strategies

4.1 GENERAL OVERVIEW OF HEALTH HUMAN RESOURCE DEVELOPMENT 4.2 LACK OF RELIABLE DATA FOR PLANNING 4.3 HEALTH HUMAN RESOURCE DEVELOPMENT – CURRENT SITUATION 4.4 E-LEARNING 4.5 IN-SERVICE TRAINING 4.6 PROVINCIAL AND DISTRICT HEALTH DEVELOPMENT CENTRES 4.7 PROPOSED KEY STRATEGIES – HUMAN RESOURCE DEVELOPMENT 4.8 BUILDING FACULTY STRENGTH 4.9 LEADERSHIP DEVELOPMENT 4.10 PROPOSED KEY STRATEGIES – LEADERSHIP DEVELOPMENT 4.11 CME & CPD OF DOCTORS- CURRENT SITUATION IN PUNJAB 4.12 ANALYSIS 4. 13 UNIVERSITY OF HEALTH SCIENCES 4.14 ACCREDITATION OF CONTINUING MEDICAL EDUCATION 4.15 THE COLLEGE OF PHYSICIANS AND SURGEONS PAKISTAN 4.16 COMMUNITY ORIENTED MEDICAL EDUCATION 4.17 MANAGEMENT QUALIFICATIONS 4.18 PROPOSED KEY STRATEGIES – EDUCATION AND TRAINING 4.19 PRE-SERVICE AND IN-SERVICE TRAINING OF NURSE PROFESSIONALSCURRENT SITUATION IN PUNJAB 4.20 NURSES IN-SERVICE TRAINING INSTITUTIONS 4.21 ANALYSIS OF PRE-SERVICE AND IN-SERVICE TRAINING 4.22 PROPOSED KEY STRATEGIES 4.23 REGULATING THE NURSING PROFESSION 4.24 PROPOSED KEY STRATEGIES

41 42 43 43 43 44 44 47 47 48 49 49 50 51 51 52 52 53 55

SECTION FIVE: RECRUITMENT AND RETENTION

5.1 5.2 5.3 5.4 5.5 5.6 5.7 5.8 5.9 5.10 5.11

63 63 65 68 71 73 73 73 74 75 75

GENERAL OVERVIEW OF RECRUITMENT AND RETENTION THE RECRUITMENT PROCESS IN PUNJAB RECRUITMENT AND RETENTION – CURRENT SITUATION IN PUNJAB ANALYSIS OFF RECRUITMENT AND RETENTION- DOCTORS GENERAL FACTORS INFLUENCING RETENTION OF DOCTORS INCENTIVES POSTING NEWLY QUALIFIED DOCTORS TO RURAL AREAS REMUNERATION PACKAGES AFFECTING RETENTION RETENTION IN PUBLIC SERVICE OR SETTING UP IN PRIVATE PRACTICE SUPPORTING RETENTION WITH SUCCESSION PLANNING RETENTION – MIGRATION

57 57 58 60 60

5.12 RECRUITMENT AND RETENTION – KEY CHALLENGES 5.13 PROPOSED KEY STRATEGIES – RECRUITMENT OF DOCTORS 5.14 SUMMARY OF KEY POINTS FOR EFFECTIVE RECRUITMENT PRACTICE 5.15 STRATEGIES TO STIMULATE RECRUITMENT OF LOCAL PEOPLE 5.16 DEVELOP SUPPORT NETWORKS 5.17 PROFESSIONAL DEVELOPMENT OPPORTUNITIES 5.18 PROPOSED KEY STRATEGIES – RETENTION OF DOCTORS 5.19 SELECTION OF FEMALE MEDICAL STUDENTS 5.20 KEY STRATEGIES FOR ADDRESSING THE GENDER IMBALANCE 5.21 CAREER COUNSELLING 5.22 TAKING LESSONS FROM INTERNATIONAL MODELS 5.23 OVERVIEW OF RECRUITMENT AND RETENTION 5.24 RECRUITMENT PROCESS 5.25 RECRUITMENT AND RETENTION – CURRENT SITUATION IN PUNJAB 5.26 ANALYSIS OF RECRUITMENT AND RETENTION – NURSE PROFESSIONALS 5.27 SHORTAGE OF SANCTIONED POSITIONS IN VARIOUS CATEGORIES 5.28 POOR IMAGE 5.29 UNATTRACTIVE SALARY PACKAGES AND POOR WORK ENVIRONMENT 5.30 MIGRATION 5.31 NURSES RETENTION AND MIGRATION – AN INTERNATIONAL PERSPECTIVE 5.32 PROPOSED KEY STRATEGIES 5.33 RECRUITMENT AND RETENTION OF LHW- AN OVERVIEW 5.34 RECRUITMENT PROCESS OF LHW 5.35 RETENTION OF LHW 5.36 ANALYSIS – RECRUITMENT AND RETENTION OF LHW 5.37 PROPOSED KEY STRATEGIES – RECRUITMENT AND RETENTION OF LHWS 5.38 RECRUITMENT AND RETENTION OF PARAMEDICS - AN OVERVIEW 5.39 RECRUITMENT OF PARAMEDICS 5.40 RETENTION OF PARAMEDICS 5.41 ANALYSIS – RECRUITMENT AND RETENTION OF PARAMEDICS 5.42 PROPOSED KEY STRATEGY – RECRUITMENT AND RETENTION OF PARAMEDICS

77 77 79 80 80 80 80 82 83 84 84 86 86 87 88

SECTION SIX: PERFORMANCE MANAGEMENT

101

6.1 6.2 6.3 6.4 6.5 6.6

102 102 103 106 106 106

PERFORMANCE MANAGEMENT - GENERAL OVERVIEW PERFORMANCE MANAGEMENT IN PUNJAB LINE MANAGEMENT PERFORMANCE MANAGEMENT - CURRENT SITUATION IN PUNJAB ANALYSIS OF PERFORMANCE MANAGEMENT – DOCTORS REWARD AND RECOGNITION

89 89 89 90 91 93 96 96 97 97 98 99 99 99 99 100

6.7 JOB DESCRIPTIONS 6.8 PROPOSED KEY STRATEGIES – PERFORMANCE MANAGEMENT OF DOCTORS 6.9 DEVELOPMENT OF A PERFORMANCE MANAGEMENT SYSTEM 6.10 DEPLOYMENT OF A PERFORMANCE MANAGEMENT SYSTEM 6.11 PERFORMANCE MANAGEMENT OF NURSE PROFESSIONALS- CURRENT SITUATION IN PUNJAB 6.12 ANALYSIS - PERFORMANCE MANAGEMENT OF NURSE PROFESSIONALS 6.13 PROPOSED KEY STRATEGIES FOR PERFORMANCE MANAGEMENT OF OF NURSE PROFESSIONALS 6.14 CURRENT SITUATION - PERFORMANCE MANAGEMENT FOR LADY HEALTH WORKERS 6.15 ANALYSIS – PERFORMANCE MANAGEMENT LHW 6.16 MOBILITY OF LHW SUPERVISORS 6. 17 PROPOSED KEY STRATEGIES – PERFORMANCE MANAGEMENT OF LHWS 6.18 CURRENT SITUATION - PERFORMANCE MANAGEMENT FOR PARAMEDICS

107 107

SECTION 7: PROMOTION

117

7.1 7.2 7.3 7.4 7.5 7.6 7.7 7.8 7.9 7.10 7.11 7.12 7.13 7.14 7.15 7.16 7.17 7.18 7.19

PROMOTION – GENERAL OVERVIEW PROMOTION IN PUNJAB AN OVERVIEW OF PROMOTION OF DOCTORS PROMOTION – CURRENT SITUATION IN PUNJAB ANALYSIS OF PROMOTION - DOCTORS PROPOSED KEY STRATEGIES- PROMOTION OF DOCTORS PROMOTION STRATEGY PROMOTION OF NURSES- CURRENT SITUATION IN PUNJAB BASIC PAY SCALE ANALYSIS OF PROMOTION PROPOSED KEY STRATEGIES – PROMOTION OF NURSES PROMOTION OF LHVs– CURRENT SITUATION IN PUNJAB PROMOTION OF LHVs –ANALYSIS PROPOSED STRATEGIES FOR PROMOTIONOF LHVs PROMOTION OF MIDWIVES– CURRENT SITUATION PROPOSED SERVICE STRUCTURE FOR MIDWIVES PROMOTION OF LHW– CURRENT SITUATION ANALYSIS – PROMOTION OF LHW PROMOTION OF PARAMEDICS- CURRENT SITUATION

SECTION EIGHT: POLICY TRIGGERS 8.1 8.2

POLICY TRIGGERS – OVERVIEW KEY POLICY TRIGGERS FOR HEALTH HUMAN RESOURCES IN PUNJAB

108 108 109 109 111 113 113 113 114 115

118 118 120 120 121 122 123 125 126 126 126 131 131 131 134 134 137 137 138

139 140 140

SECTION NINE: INTERNATIONAL MODELS AND PERSEPTIVES

145

9.1 9.2 9.3 9.4 9.5 9.6 9.7 9.8 9.9

146 146 147 151 155 159 162 165 165

INTERNATIONAL PERSPECTIVE CONTEXT BANGLADESH MALAWI AUSTRALIA CANADA TANZANIA SUMMARY KEY STRATEGIES RECOMMENDED FOR CONSIDERATION IN PUNJAB

SECTION TEN: EMERGING ISSUES FINANCIAL IMPLICATIONS RECOMMENDATIONS ANNEXURE REFERENCES

167

ACRONYMS

AIDS

Acquired Immune Deficiency Syndrome

ARI

Acute Respiratory Infections

APMO

Additional Principal Medical Officer

ACR

Annual Confidential Report

Assistant Director

AIMC

Allam Iqbal Medical College

ADB

Asian Development Bank

BScN

Bachelor of Science in Nursing

BHU

Basic Health Unit

BPS

Basic Pay Scale

Basic Scale

BOD

Burden of Disease

CHC

Community Health Centre

CMW

Community Midwives

CME

Continued Medical Education

CPSP CPD

College of Physicians and Surgeons Pakistan Continuous Professional Development

Deputy Director

DOH

Department of Health (Punjab)

DGHS

Director General Health Services

DCO

District Coordination Officer

DHQH

District Head Quarters Hospital

DiFD

Department for International Development

DHDC

District Health Development Centre

DHIS

District Health Information System

DOH

District Officer Health

EDO

Executive District Officer

EmONC

Emergency Obstetric and New born Care

EDL

Essential Drugs List

EOC

Essential Obstetric Care

EDO-H

Executive District Officer Health

EPI

Expanded Programme of Immunization

Family Planning

FCPS FLCFs

Fellows of College of Physicians and Surgeons First Level Care Facilities

FPUI

Federal Programme Implementation Unit

GoP

Government of Pakistan

GoPb

Government of Punjab

HHR

Health Human Resource

HIS

Health Information System

HMIS

Health Management Information System

HSRP

Health Sector Reforms Programme

HSRF

Punjab Health Sector Reform Framework

HRMIS HIV

Human Resource Management Information System Human Immunodeficiency Virus

Human Resource

HRD

Human Resource Development

HRM

Human Resource Management

HRP

Human Resource Planning

IMR

Infant Mortality Rate

HSRP

Health Sector Reform Programme

IPH

Institute of Public Health

ICM

International Confederation of Midwives

ICN

International Council of Nurses

LHV

Lady Health Visitor

LHW

Lady Health Worker

MIS

Management Information System

MScN

Master of Science in Nursing

MSDS

Minimum Service Delivery Standards

MCH

Maternal Child Health

MMR

Maternal Mortality Ratio

Medical Officer

Medical Superintendent

MAP

Midwifery Association of Pakistan

MDGs

Millennium Development Goals

MNCH

Maternal Neonatal and Child Health

MSDS

Minimum Service Delivery Standards

MOH

Ministry of Health (Pakistan)

M&E

Monitoring & Evaluation

NGOs

Non Government Organizations

NEB

Nursing Examination Board

PAIMAN

Pakistan Initiative for Mothers & Newborns

PMDC

Pakistan Medical and Dental Council

PNC

Pakistan Nursing Council

PNF

Pakistan Nursing Federation.

PDSSP PHC

Punjab Devolved Social Services Programme Primary Health Care

PMO

Principal Medical Officer

PMDGP PSC

Punjab Millennium Development Goals Programme Public Service Commission

PHDC

Provincial Health Development Centre

PLGO

Punjab Local Government Ordinance

Registered Midwife

Registered Nurse

RHC

Rural Health Centre

SHC

Secondary Health Care

SMO

Senior Medical Officer

THQH

Tehsil Head Quarters Hospital

TOR

Terms of Reference

United Kingdom

United Nations

UNICEF

UHS

United Nations International Children Education Fund United States Agency for International Development University of Health Sciences

WMO

Woman Medical Officer

USAID

GLOSSARY OF TERMS

Accreditation The assessment and recognition of level of Quality of an organization such as an educational institution or a hospital by peer reviewers against a set of agreed standards, following a self-assessment by the organization. The recommendation by the peer reviewers is approved by an independent review board Accreditation A standard is an established norm or requirement. Accreditation Standards standards are contained in a formal document with uniform criteria, methods, processes and practices that an institution demonstrates in order to achieve the accreditation status. Standards cover management, service provision and user requirements Burden of Disease

BOD is “an aggregate measure of the years of healthy life lost by a population due to all episodes of disease and injury occurring in a given year”. It is a direct measure of the prevailing health problems. BOD helps in determining problem based health needs of the population which in turn determine nature of services to be provided at all levels of care

Clinical Placement

A period of time arranged for a student nurse, Lady Health Visitor or midwife to spend in a specified clinical area as part of their educational programme

Clinical Preceptor

A skilled nurse or a midwife who is registered by the Pakistan Nursing Council and has completed an approved course to provide guidance and teaching to nurses, midwives and Lady Health Visitors when they are obtaining practical clinical experience in the workplace (in a clinical placement)

Continuous Professional Development

CPD can also be defined as the conscious updating of professional knowledge and the improvement of professional competence throughout a person's working life. It is a commitment to being professional, keeping up to date and continuously seeking to improve.It is the key to optimizing a person's career opportunities, both today and for the future (Chartered Institute of Professional Development (2000))

Continuing Medical Education

Continuing medical education (CME) refers to a specific form of continuing education (CE) that helps those in the medical field maintain competence and learn about new and developing areas of their field

Health Visiting

In this document this term is used to indicate the work of Lady Health Visitor, distinct from Nurse and Midwife

Minimum Service Delivery Standards (MSDS)

MSDS are defined as “minimum level of services, which the patients and service users have a right to expect”. MSDS include minimum package of services, standards of care (level specific) and mandatory requirements/system specifications that must be complied with and are vital to ensure the delivery of these services

Nursing

It would encompass 3 cadres (Nurses Midwifes Lady Health Visitors) unless specified otherwise

Primary Health Care (PHC)

PHC is â&#x20AC;&#x153;Essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families

Registered Community Midwife

To be a registered midwife in Pakistan, one must complete a 12 month diploma after a 3 year diploma in general nursing or a 15 month diploma in midwifery after completing grade 10 school education OR to be a registered community midwife, one must complete an 18 month diploma after grade 10 school education

Registered Lady Health Visitor

To be a registered lady health visitor in Pakistan, one must complete a one year diploma in Public Health after a one year diploma in midwifery

Registered Nurse

To be a registered nuse in Pakistan, one must complete a 3 year general nursing diploma,or a 4-year BScN degree

Skill-mix

This refers to the mix of health staff based on the roles, experience and activities that different categories of staff have. Rather than having all junior or all senior staff, or all nurses or all LHVs, a mix of experience and of staff type is used to achieve a more efficient workforce in a particular setting

Standard Operating Procedure (SOPs)

Detailed description of steps required in performing a task

Standardized Medical Protocols (SMPs)

Standard steps to be taken by a health facility during medical or surgical management of a patient

Standards of practice

Standards of practice describe the criteria, activities/behaviour and practices that a profession requires its members to meet. They are used to assess competency to practice within the discipline and are closely aligned to the scope of practice of the discipline

KEY WORDS

Health Human Resources Human Resource Planning Human Resource Management Human Resource Development Manpower Planning Recruitment Retention Performance Management Promotion Training and Education Doctors Nurses Lady Health Visitors Midwives Lady Health Worker Paramedics

AKNOWLEDGEMENTS

The Consultants would like to acknowledge the doctors, nurses, Lady Health Visitors and midwives who contributed wholeheartedly toward the development of this report and saw it as a hope for a better tomorrow! We also acknowledge the contributions from all staff of the health department who gave their time and valuable insights to make this report more meaningful and grounded in reality.

EXECUTIVE SUMMARY

Within the broader framework of the Punjab Devolved Social Service Programme and the Health Sector Reform Programme including the Punjab Millennium Development Goals Programme this assignment was commissioned with the specific focus of human resources for health in Punjab. Section 1 outlines the methodology and framework for the study. This study has examined the key human resource issues facing the Punjab health department in respect of recruitment and retention, performance management and promotion in relation to six cadres of health care providers; nurses, doctors, Lady Health Visitors, paramedics, Lady Heath Workers and Community Midwives. Additionally international models from various countries were reviewed in respect of human resource issues with a view to learning from other practices that may supplement or offer alternatives for the health department of Punjab. Section 9 provides some insights into five countries facing similar human resource issues to Punjab. The study has revealed that the human resource issues currently facing the health department in Punjab are complex, multifaceted and challenging to address. One of the most significance issues highlighted by this study is the lack of a comprehensive, dedicated health human resource department and HRMIS staffed by personnel trained in human resource management functions within the health department. The key recommended strategy is to establish and resource a fully functioning human resource department supported by a HRMIS computer data base with skilled operatives and supporting resources. Readers interested to read more on this are referred to Section 3. The recruitment of health staff in general lacks uniformity in terms of a transparent and systematic approach and is generally not well founded on sound human resource best practice and principles. It is recommended that an effective and fully transparent recruitment process is developed and institutionalised for the recruitment of all staff at all levels. Readers interested to read more on this are referred to Section 5. Analysis indicated that retention of staff is compromised by several factors relating to the work environment, education and training opportunities, human resource management protocols and more attractive alternatives. Recommendations are made on how to address these issues. Readers interested to read more on this are referred to Section 4 and 5. The study found that performance management currently based on the Annual Confidential Report process is rather outdated and highly subjective. Application is less rigorous than required and not based on standard protocols. Significantly line managers are not trained in how to conduct performance reviews and staff are unaware of the benefits of effective performance management. Readers interested to read more on this area are referred to Section 6. With reference to promotion the study highlighted that although there is a government BPS grading and scale system operational within the health department of Punjab it is widely acknowledged that it lacks transparency and varies significantly in its application. 1

Additionally as promotion is not based on an effective performance management system it lacks credibility. Readers interested to read more on performance management are referred to Section 7. Further the study revealed that all cadres lack a fully structured career pathway with clear requirements in terms of education, qualifications and experience. Readers interested to read more on this are referred to Section 3. Additionally other key human resource issues highlighted by the study and linked inextricably with recruitment and retention, performance management and promotion include; imbalances between the cadres, gender imbalances, lack of a management cadre, deficiencies in faculties and a general lack of quality continuing education and professional development opportunities for all cadres. Options and strategies to address these issues are presented in the appropriate sections. The study also revealed several areas that would benefit from further assessment and study and these are highlighted in Section 10.

STRATEGIC FRAMEWORK Section One

1.1 INTRODUCTION

Within the broader framework of the Punjab Devolved Social Service Programme and the Health Sector Reform Programme, including the Punjab Millennium Development Goals Programme, this assignment was commissioned with a specific focus on health human resources in Punjab. The key objective of PDSSP, supported by the Asian Development Bank and the Department for International Development UK, is the improvement of social sector service delivery in health, education and water and sanitation. The overall goal is to achieve progress on the MDGs in Punjab. Similarly the HSRP is underpinned by the PMDGP to support the Punjab government in the attainment of the MDGs, in particular the reduction of infant and maternal mortality rates, through improved access to quality, equitable health care services at both primary and secondary levels. This also includes a significant area of work on the development and implementation of Minimum Service Delivery Standards. Of key significance to all these commendable initiatives is that of health human resources as no health care delivery system will be able to achieve its goals unless the appropriate human resource capital is in place to deliver health care services. This study will examine the key human resource issues facing the Punjab Health Department in respect of recruitment and retention, performance management and promotion in relation to six cadres of health care providers; nurses, doctors, Lady Health Visitors, paramedics, Lady Health Workers and Community Midwives.

1.2 METHODOLOGY

1.2.1

Methods

A two stage approach was used for this assignment keeping in view the Terms of Reference, the timeframe and the required output. Stage One Stage one involved a literature search and desk review approach to research papers, reports and articles identified by the Punjab Devolved Social Services Programme and Health Sector Reform Programme. Also the main appropriate bibliographic databases and grey literature found through national and international contacts were reviewed. The literature search was based on the three key human resource parameters identified in the ToR, recruitment and retention, performance management and promotion and the six key cadres of health workers similarly identified in the ToR. The search was mainly limited to Punjab, Pakistan and four or five comparator countries i.e. Bangladesh, Canada, Australia, Malawi and Tanzania; particularly for countries with similar health human resource issues. 2

Stage Two Stage two was the qualitative arm of the assignment and involved interviews of stakeholders and key informants, focus group discussions and two consultative workshops including senior health officials, principals of medical colleges and heads of training institutions including professors, nurse tutors and other faculty members; doctors, nurses, LHVs, LHWs, paramedics and community midwives from primary and secondary health care facilities; health administrators at provincial and district levels, senior health civil servants, department of health senior finance staff and representatives of donor agencies and projects. A complete list of key informants is attached as Annex 1. Information and data was reviewed and analysed and grouped into key areas which form the basic structure of the report: assessment and analysis of the current situation; key challenges and strategies. Considering the limited time of the assignment and the wide scope of work and limited timeframe the cadres were divided between the two consultants. The doctors, paramedics and LHWs were largely assessed and analysed by the International Consultant, and the remaining three cadres, nurses, midwives and LHVs were evaluated and analysed by the National Consultant. Dr Shabnum Sarfraz, the National Consultant   



Conducted a detailed situation analysis of nurses, lady health visitors and midwives; Identified key challenges facing the Nurses, Lady Health visitors and Midwives; Reviewed and analyzed the present health care manpower planning and management by HD and the District Government in terms of recruitment, performance evaluation and promotion systems, and policies and regulations related to nurses, Lady Health visitors and Midwives; Investigated the institutional capacity of pre-service and in-service training for Nurses, Lady Health visitors and Midwives

She went on to developing strategies for improving efficiency of nursing workforce planning and management over the short, medium, and long terms in consideration of international and domestic best practices. A comprehensive health human resources plan proposing rationalisation of service for nurses, Lady Health visitors and Midwives was also proposed by her. Dr Shabnum Sarfraz, the healthcare human resource specialist benefitted from her extensive experience in the healthcare sector and her recent assignments on National Nursing Policy. She held extensive stakeholder consultations through individual interviews, focus group discussions in order to get firsthand knowledge about the issues and challenges facing the nursing profession in Punjab. She delivered a consultative workshop for GoPb and other Nursing, LHVs and Midwifery Stakeholders on international best practices on heath care man power planning and management shared the proposed strategies with the stakeholders and obtained their feedback. This feedback was incorporated by her into the sections on Nurses, Lady Health visitors and Midwives, of the final report. She went on to support the IC in the preparation of the final report.

On the basis of an extensive insight developed into the Nursing Professions during the course of this assignment, the National consultant has proposed further areas of study in line with the present assignment which are detailed in Section 10.

1.3 CONSULTANTS COMMENTS ON THE TERMS OF REFERENCE RATIONAL

1. It is important to underline that overall the ToR and scope of work was extremely over ambitious and too broad for the number of person months available i.e. six person months in total. To achieve as much as was possible within the given timeframe both consultants had to work extremely hard and well beyond the number of hours usually associated with such assignments. 2. In the view of both consultants it would require at least three person months just to adequately address one cadre of health worker. In the case of nurses more time would be required. 3. Recommendations are made within this report in Section 10 for further areas of study that would benefit from more in depth attention and focus. 4. The situational analysis was undertaken by both national and international consultants simultaneously rather than by the national consultant one month prior to the start of the assignment by the international consultant as was first envisaged in the ToR. 5. With reference to the paramedics cadre; in view of the fact that a fully comprehensive study had already recently been completed by other consultants for this cadre and the recommendations approved for implementation it was agreed with key stakeholders that this study would not need to duplicate this area of work. Therefore less priority was given to the paramedic cadre in this study however; reference was made as appropriate in each section. 6. In view of the above comments and the opinion of the consultants there was insufficient time available for the full costing exercise referred to in the ToR. A rather more superficial exercise has been completed. Additionally it is recommended that a health finance specialist would be required for at least 15 days to undertake this exercise in full. 7. With reference to international models the consultants felt that any models proposed must be grounded in the local context and based on the actual situation in Punjab; the contextual approach is more important. References have been made to some international models within various sections.

1.4 SUMMARY OF THE CONCEPTUAL FRAMEWORK FOR THE TERMS OF REFERENCE

It was understood that the basis of the scope of work within the Terms of Reference is the Minimum Service Delivery Standards linked to the Punjab Millennium Development Goals Programme framework. The key scope of work was based on an assessment and analysis of the existing situation in terms of pre and in-service training capacity, the existing HR capacity for the six cadres indicated in the ToR; doctors, nurses, midwives, LHWs, LHVs and paramedics and the 4

relevant service rules and regulations within the Punjab health department to meet the recommendations of the MSDS. Additionally strategies, taking into account international best practice and national models if demonstrable, were developed and costed for the short, medium and long term. While the basis for information and data for this report is literature and desk reviews supported by key informant meetings, focus group discussions and two consultative workshops, it is acknowledged that certain aspects of the report would benefit from more rigorous data collection. Relevant data from within the health sector in Punjab was difficult to access at times and was incomplete in many instances. While every attempt has been made to cross check and cross reference various sources for data, it is recognised that different sources frequently provided different data for the same item, particularly from internet sites. The model below indicates the key areas that were addressed within the scope of work:

The Conceptual Model

Context MSDS and PMDGP

Current Situation Assessment and Analysis Current staffing levels Pre-service training capacity

Gaps

Solutions Strategies

Challenges to meet MSDS Staffing

Models and international best practice

Productivity

Recruitment Performance Promotion

Policies and regulations for In-service training capacity Recruitment Performance Promotion

Recruitment Performance Promotion

Policies and regulations

Cost Implications

1.5 BACKGROUND

1.5.1

Health Strategies

Health care in Pakistan and in Punjab in particular, has over the past thirty years, undergone many changes moving from a largely curative approach to one based more on primary health care following the signing of the Alma-Ata Declaration in 1978. This was followed by the significant expansion of the health infrastructure during the 1980s to include a Basic Health Unit in each union council covering an estimated population of 15,000 to 20,000 and a Rural Health Centre serving a cluster of four to five union councils 1. Similarly Tehsil and District level hospitals were established to provide secondary level care with large hospitals providing more specialised care at tertiary level in all major cities. Pakistan has a health service environment that is challenged by the impact of poverty, a changing burden of disease, communicable, non-communicable and lifestyle, and the lack of access to quality health services for its rural population. The situation is further complicated by increasing numbers both of the aged population and young age groups. More recently the focus has been on increased access, quality, equity and improved efficiency and productivity to meet the changing and increasing needs of the population. The Millennium Development Goals, with a particular emphasis on maternal and child health are being given priority. With the strong link between poverty and ill-health now well established there is also a need to provide pro-poor health care services. 1.5.2

Private and Informal Sectors

A further factor for consideration in Pakistan and Punjab is that of the private and informal sector; this sector is so large that it cannot be ignored when considering health care. It is estimated that over 70 percent of the population access private health care and in rural areas the informal sector is often the first and preferred option for health care by the majority of the local community. Ironically in spite of having a much smaller share of the market both government and donors, almost without exception until very recently, have targeted public sector health systems. This has largely left the private and informal sectors to flourish without regulation. It is recommended that a further comprehensive study would be required to review, audit and make recommendations for both the private and informal sectors contributions to health care provision. Some reference may be made to suggestions and options as they arise within the broad context of this work. 1.5.3

Millennium Development Goals

In the context of the Millennium Development Goals, commonly acknowledged to be a valid and a mutually reinforcing framework for measuring development progress, new challenges have arisen for health care providers, decision makers and policy makers in Punjab.

Ministry of Health

Three of the eight MDGs address health issues, in particular aiming to improve maternal health and reduce child mortality; combating HIV and AIDS and Malaria and Tuberculosis being the other key focus areas. Pakistan is a signatory to the Millennium Declaration and is committed to achieving the Millennium Development Goals set for 2015. The countryâ&#x20AC;&#x2122;s targets for MDG-5 are to reduce the MMR to less than 140, and to increase skilled birth attendance to 90 percent by the year 20152 The MDGs constitute the main goals that the Punjab health department has to target in the medium term. The MDGs framework itself sets challenges in respect of human resources for health. Integrating the targets for achieving the MDGs into national planning is not straightforward and requires additional commitments and resource allocation in terms of funding and human resources. Current specialists, nursing, midwifery and health visiting workforce shortages will reduce the likelihood that these goals become a reality not only for Punjab but also for Pakistan as a whole. 1.5.4

Health Sector Reform Framework

The government of Punjab is pro-actively seeking ways in which to address health human resource issues with a specific focus on maternal and child health and quality service provision. In this regard the health department has recently embarked upon an ambitious health sector reform programme based on the Health Sector Reforms Framework. This has been developed through an extensive consultative process and is contingent upon several inter-linking health care initiatives. Pivotal in this is the Punjab Millennium Development Goals Programme to be implemented from 2008 to 2011 and designed specifically to support the government of Punjab health department in the achievement of the Millennium Development Goals Additionally, the reform programme aims to improve access, quality and equity of health services focusing on sustainable pro-poor financing, more efficient delivery of appropriate services and the achievement of minimum care standards across the health sector. 1.5.5

Punjab Devolved Social Services Programme

Over-arching and integral to the health sector reforms programme is the Punjab Devolved Social Services Programme currently under implementation across the province. The key objective is improving social service delivery in health, education, water supply and sanitation. The programme is designed to support the devolution of social services covering all 36 district governments across Punjab supported by a substantial technical assistance programme under the aegis of the Planning and Development Department as the executing agency.

Ministry of Health 2005

1.6 CONTEXT

1.6.1

Historical Perspective

In 1947 Pakistan had just two medical colleges; in 2009 there are over 70 medical and dental colleges and 109 nursing schools, seven nursing colleges, twenty-six public health schools training LHVs and 141 midwifery training schools3 across the country. There are 32 medical schools in the public sector and 39 in the private sector. This has increased the number of doctors from 78 in 1947 to over 137,400 in 2009 including around 22,400 specialists4 and an estimated 25,000 working overseas.5 Similarly the number of nurses has risen from less than 400 in 1947 to almost 48000 in 2009. Further, in 1947 Pakistan had just 292 hospitals providing almost 14,000 beds; today Pakistan has 920 public sector hospitals and around 800 in the private sector6 providing well over 100,000 hospital beds. Additionally, with the increased focus on Primary Health Care following the Declaration of Alma-Ata in 1978, Pakistan began to develop and expand health services and facilities in rural areas to meet the growing needs of a largely rural population and a c0ommitment to primary health care. By the late 1980s a considerable health infrastructure had been developed across Pakistan including Basic Health Units in each union council and a Rural Health Centre covering four to five union councils. To date there are more than 550 RHCs and 4,870 BHUs with an additional 4,916 dispensaries, compared to around 700 dispensaries7 in 1947, and 1,138 MCH centres across Pakistan.8 In Punjab alone there are 19 teaching hospitals providing almost 12,000 beds.

Table 1: Public Health Facilities in Punjab9

Type of Facility

Number

Beds

Teaching Hospitals

11,964

DHQ Hospitals

5,799

THQ Hospitals

3,338

RHCs

296

5,986

BHUs

2456

4,866

Other hospitals

3,463

PNC, March 2009 PMDC July 2009 5 Scope of Medical Colleges in Private Sector; A.J.Khan 6 National Health Policy â&#x20AC;&#x201C; Zero draft 2009 7 Population Assoc. of Pakistan 8 Ministry of Health 2007 9 Department of Health Punjab 4

Dispensaries

213

318

TB Clinics

MCH Centers

188

Sub Health Centers

574

Total

3946

35810

This trend has significantly increased the need for trained health personnel at all levels, particularly doctors and nurses. In more recent years it has involved the establishment of new cadres, most notably Lady Health Workers and Community Midwives in order to provide basic health care to more people, especially rural women and children. This in itself has posed many challenges for the health department and in an effort to increase absolute numbers other key aspects of human resource planning, management and development have perhaps received less than desirable attention. 1.6.2

Health Indicators

The past few years have seen some improvement in economic growth however, the social indicators remain challenging and Pakistan is currently lagging behind if it is to achieve the Millennium Development Goals by 2015. The under-five mortality rate in Pakistan remains high at 94 per 1000 live births with diarrhoeal diseases and ARI as the main causes; infant mortality stands at 78 per 1000 live births and maternal mortality ratio at an estimated 276 per 100,000 live births10. 1.6.3

Policy Framework

The overall responsibility in terms of policy direction and planning for health services rests with the Federal Government through the Ministry of Health. Additionally the Federal Government retains responsibility for various vertical programmes including the National Programme for Family Planning and Primary Health Care â&#x20AC;&#x201C; the Lady Health Workers programme, the Expanded Programme of Immunisation, Malaria and TB Control Programmes, nutrition programme, MNCH, Punjab Millennium Development Goals Programme and the National AIDS Control Programme. The actual delivery of health care services prior to 2001 was the responsibility of the provincial governments. The Director General Healthâ&#x20AC;&#x2122;s Office was responsible for providing services through posting of staff at district and sub-district levels. The medical staff, through various Directors of Health, reported to the DG Health Office. 1.6.4

Health Care under Devolution

Following the implementation of the Local Governance Ordinance in 2001, health, together with other social services was devolved almost entirely to the district governments. This 10

WHO, 2007

included health services in BHUs, RHCs, maternal and child health care, population welfare and DHQ and THQ hospitals. The major exception was that of teaching hospitals and the attached medical colleges which remained under the direct control of the provincial government. Under this devolution process the Executive District Officer-Health became responsible for health care services within the district, including the control of all medical staff, under the direct authority of the Zila Nazim who exerts his authority through the EDOH, the District Coordinating Officer and the District Health Committee. Additionally the DG Health also remained in control at the provincial level primarily with respect to policy formulation and regulation, setting standards, resource mobilisation and allocation. Similarly the DGH remained responsible for technical support in areas of monitoring and evaluation and professional development of health staff. The districts, through the Nazim, the DCO and the District Committees, are the key administrative bodies responsible for implementation of policies at the district level. The provincial health department is headed by the Minister for Health supported by the executive, civil service, body headed by the Secretary Health. There are a number of Additional Secretaries and Deputy Secretaries with various roles and responsibilities. In Punjab the DG Health had a limited role in service delivery and the Director Health post was largely responsible for vertical programmes only. The provincial government continues to provide funding to the districts for all the health care services with the exception of several vertical programmes such as the LHWs programme which continues to be funded by the federal health department. At the time of writing this document the government of Punjab is working to adjust some of the devolution protocols and return to the system of Divisions and District Commissioners with proposed changes to the devolutionary powers of the districts. This will in effect, bring the administrative control of the districts back to the centre through the appointment of district administrators i.e. District Commissioners, in place of the elected Zila Nazims under the fully devolved model. Nine Divisional Headquarters have been notified each with a responsibility for three, four or more districts. At the divisional headquarters level the new Administrator for health has been notified as the Divisional Director Health Services responsible directly to the provincial health secretariat and DGH. It seems likely that the EDOH will become the District Health Director and will be accountable to the Divisional Director Health Services at the Divisional level. This is work in progress and rules and regulations have yet to be formulated. The proposed revisions need to be approved by the Federal Government for implementation of this modified model to proceed. 1.6.5

Human Resource Management under Devolution

Within the devolved framework in respect of the District Coordination Officer and the EDOs, including the EDOH human resource management is standardised across the province.Management control of medical staff, doctors, LHVs and nurses, is exercised by 10

both the provincial and district government. All the health department staff of the districts report to the EDOH. The authority for posting and transfer are distributed among the district administration according to the BPS Grade. The provincial government retains the control for administrative staff. The authority for recruitment, contracting, promotion, transfers, disciplinary action and dismissal for all district staff varies within the different provinces. In Punjab these HR functions have been devolved to the EDOH who sends recommendations to the DCO for final approval and both the EDOH and the DOH have authority for recruitment, transfer and dismissal according to BPS Grades i.e. the DOH has authority up to Grade 4 and the EDOH up to Grade 15 and Grade 16 in the case of nurses. There is no overall dedicated health human resource department or HRMIS with dedicated, trained HR staff within the health department. Rather it remains largely an administrative function and is grossly under resourced. Additionally the HR function remains split between the civil service, the health secretariat, and the health department at both district and provincial levels. The teaching hospitals and attached medical colleges remain autonomous and therefore largely outside the purview of the health department administration. Similarly is the case for the staff of vertical programmes.

HEALTH HUMAN RESOURCE FRAMEWORK SECTION TWO

2.1 GENERAL OVERVIEW Health care provision is highly labour intensive and human resources play a critical role in health care delivery. For the service to be truly effective it is imperative to have the right number of health care providers with the right level and mix of skills in the right place at the right time. Additionally staff need to be supported by appropriate and adequate resources to enable them to do their work i.e. health care provision. This may sound simplistic but in reality probably poses the biggest challenge yet to the Punjab government in terms of health care delivery. Building, retaining and managing a skilled and motivated health workforce is a demanding task and presents a multitude of challenges. These include, but are not limited to:



Population size



Public and staff expectations



Disease patterns and prevalence



Socio-economic influences



Further influences of gender, age, location and levels of education.

These are then further influenced by the behaviours of the health care workers themselves e.g. doctors ordering more tests require more trained laboratory technicians. A sustained and committed effort is now required to address the challenges of health human resource issues within the Punjab health department. This requires a collaborative approach bringing together planners, policy makers, financers, researchers and health care workers to assess and address the core issues. Furthermore it is important to develop and put in place sustainable mechanisms for short, medium and long term improvement in the production, recruitment, retention, performance and professional development of health care providers. These need to be supported by robust policies and procedures that are vigorously applied across all levels and all cadres. Addressing these issues will contribute significantly to ensuring that a minimum standard of safe and effective health care services are available and accessible to the population. Likewise, addressing the key human resource issues will contribute substantially to strengthening the health care workforce and the environment in which they operate. 13

2.2 PRODUCTION AND RETENTION OF HEALTH CARE PROVIDERS It is incumbent upon any government to ensure that enough people enter the health care system with the appropriate education levels to benefit from pre-service and in-service training programmes to build the number of health care providers required to meet the changing needs of the population. Similarly once recruited into the health care system appropriate policies need to be in place to ensure retention and promotion of good staff. Additionally, mechanisms and support for the continuing education and professional development of staff must be in place.

2.3 EDUCATION AND TRAINING OF HEALTH CARE PROVIDERs Having a skilled and experienced workforce is also dependent upon good quality training, pre-service and in-service. New options and initiatives may need to be considered to meet modern learning trends and some of these will be presented in this document. Strengthening the capacity of training and educational institutes is an investment in the right direction. In a recent Public Private Partnership between the Government of Punjab and the Fatima Memorial Hospital College of Nursing to strengthen the nursing profession is just one such commitment shown by the government. Additionally it is vital to have acceptable minimum parameters in education and training for:

   

Professional practice Core competencies Core content Standard of education for doctors, nurses, midwifes and lhvs and all allied health professionals

2.4 HEALTH SECTOR STAFFING IN PUNJAB A high level of infrastructure as seen in the Punjab health system clearly requires a high level of staffing with a variety of cadres. The current staff strength in Punjab is over 130,500 as indicated in Table 2. This is a significant number of people for any human resource management system to provide for.

TABLE 2: HEALTH STAFF STRENGTH IN PUNJAB

CADRE

SANCTIONED POSTS

Teaching Cadre

1,103

General Cadre

9,609

Specialist Cadre

1,135

Dental Cadre

441

Nursing

6,136

Others (paramedics) including LHVs

69,208

Employees of National Programme, FP&PHC

36,243

Contract Trainees (nurses & paramedics)

6,817

Total

130,692

2.5 BASIC PAY SCALES

Salaries of government health staff are determined by the Basic Pay Scales (BPS); these are graded from 1 to 22 with 22 being the highest level. The BPS are set federally and adopted provincially. Functional authority is usually commensurate with the BPS Grade although some staff are raised to a higher BPS Grade for the purpose of a salary increase only; this may or may not be in line with performance or additional responsibilities. Under the health sector reform programme various incentives are being provided to enhance basic pay particularly for staff working in rural areas in first and second level care facilities. These are indicated in the appropriate sections. Currently almost 70 percent of the health budget is spent on staff costs.1

2.6 KEY HUMAN RESOURCE FUNCTIONS

Health care human resource planning, management and development is a challenge for the Punjab health department as they strive to find formulas to enhance the contribution of health professionals to health performance and the goal of providing quality health care to individuals, families and communities in Punjab. 1

Punjab Health Department 2008

Already a great deal of work is being undertaken in this regard specifically in respect of paramedics 2 , minimum standards for delivery of health care 3 development of job descriptions4 and overall health system strengthening5 .

2.6.1 Human Resource Planning

Strategic human resource planning, essential for an effective health care delivery system is largely absent, often donor driven and generally not need based. The development of the Minimum Service Delivery Standards6 for staffing in primary and secondary care facilities forms a framework for a more systematic and coherent human resource plan on which to base recruitment in terms of indicating standard HR staffing levels; how much of this is based on real need and effective planning is not easy to determine. The rigid application of such HR staffing standards across all the facilities in the tehsils and districts may not be the best approach; the â&#x20AC;&#x2DC;one size fits allâ&#x20AC;&#x2122; is a dangerous assumption. Variations within districts and across districts are significant in terms of health human resource requirements and these need to be reflected in the HR planning process at district level together with inflow and outflow assessments and succession planning.

2.6.2 Human Resource Management in Punjab

The management of human resources within the health department is fragmented with key responsibilities being split between the DGHS and the Secretariat, the province and the districts, regular health staff and autonomous hospitals, administration and planning. Currently the HR function within the health directorate rests with an Additional Director Administration who is also responsible for all administration and civil works. Within the Secretariat the HR functions are divided between the Additional Secretary Establishment, the Additional Secretary Administration and the Additional Secretary Technical; the key responsibilities of each are indicated in Table 3.

Paramedics proposal 2008 Minimum Service Delivery Standards for PHC in Punjab 2008, PDSSP; Contech international 4 Job Descriptions and Performance Evaluation Criteria for Medical, Nursing and Paramedical Staff 2009 5 Health Sector Reform Framework 2006 6 Minimum Service Delivery Standards for Primary and Secondary Health Care in Punjab; PDSSP, 2008 3

TABLE 3: KEY RESPONSIBILITIES OF ADDITIONAL SECRETARIES

Additional Secretary Establishment

Additional Secretary Administration

Additional Secretary Technical



All general cadres



Policies



Medical education



EDOs, Directors and District Health Staff for postings and transfers



Specialist cadres



Medical colleges, teaching institutions and attached autonomous teaching hospitals

Colleges and nursing schools in terms of curricula, admissions, eligibility criteria



All technical aspects of hospitals, dispensaries, health facilities and institutions



Standardisation of all equipment.

 

All allied health professionals All purchase procedures

2.7 MANAGEMENT OF HEALTH STAFF Management posts are largely undertaken by doctors from the general cadre many of whom do not have an appropriate management qualification or experience, and in some cases aptitude, for management and administration. Similarly although technically qualified, and in many cases significantly experienced, the medical staff of both BHUs and RHCs spend a substantial amount of time on troubleshooting and managing technical and administrative matters rather than on actual health service delivery. This is equally significant in the THQ and DHQ hospitals where the Medical Superintendent, BPS Grade 19 or 20 is unlikely to have received substantial training in general management or human resource management and yet is likely to spend up to 80 percent of her/his time on such issues. One initiative addressing this issue is the CPSP 12 month diploma programme in Health Systems Management. Additionally the CPSP Masters and Fellowship Programme in Management is still awaiting approval of the Higher Education Commission and the PMDC. Similarly the Institute of Public Health is offering training and post graduate courses in management.

Doctors 2.8 GENERAL OVERVIEW OF DOCTORS 2.8.1 Doctor Population Ratio The current doctor population ratio for Pakistan is estimated to be between 1:1,400 and 1:1,5007; although below international recognised standards relatively good by comparison with regional figures as shown in Table 4. The WHO recommended doctor population ratio for developing countries such as Pakistan is 1:1000.8

TABLE 4: REGIONAL COMPARISON OF DOCTOR POPULATION RATIO 9

COUNTRY

DOCTOR/PATIENT RATIO

Pakistan

1:1,400/500

India

1: 1,700

Sri Lanka

1: 1,800

Bangladesh

1: 3,800

Afghanistan

1: 5,300

2.8.2 Number of Doctors

Given that the current population of Pakistan is an estimated 173 million 10 this would indicate an approximate requirement of 173,000 doctors for the population of Pakistan. The current number of registered medical practitioners is 137,43311 indicating a shortfall of approximately 35,600 doctors to meet current population needs, depending also on assumptions of future need. Table 5 indicates the numbers of registered medical practitioners, both basic generalists and specialists, in Pakistan and Punjab12:

WHO WHO 9 WHO 10 CSS Forum 2008. It should be noted that various sources give varying numbers as updated census data is not available. 8

PMDC July 2009 PMDC July 2009

TABLE 5: NUMBER OF REGISTERED MEDICAL PRACTITIONERS IN PAKISTAN AND PUNJAB13

PAKISTAN GENERAL BASIC

PUNJAB GENERAL BASIC

PAKISTAN SPECIALISTS

PUNJAB SPECIALISTS

Female 47,899

19,437

5,083

2,540

Male

67,164

25,892

17,287

8,842

Total

115,063

45,329

22,370

11,382

Total RMPs in Pakistan (Basic & Specialists) = (115063+22370) = 137433 Total RMPs in Punjab (Basic & Specialists) = (45,329+11,382) = 56,711

This is a shortage that, if current doctor productivity levels across the country remained the same, approximately 6,000 per annum, and taking into account loss to migration, non practice and other factors, would take approximately ten years to meet. In Punjab the estimated population is currently around 82 million 14 and the number of registered medical practitioners 56,711. 15 This would indicate a shortfall of approximately 25,000 registered medical practitioners based on WHO recommendations. Applying the same calculation it would take at least another 12 years to meet the WHO recommended level. In spite of Punjab producing relatively high numbers of doctors each year there remains a substantial shortage of practising doctors, particularly female doctors and specialists in rural areas. This is having a direct impact on maternal and child health care service delivery across the province. Details attached in Annex 2.

2. 9 MEDICAL COLLEGES

The number of medical and dental colleges across Pakistan, both private and public, has increased tremendously over the past fifteen years; 59 are currently recognised and registered by the Pakistan Medical and Dental Council.16 In Punjab there are eleven public medical and dental colleges and 16 private ones giving a total of 27.17 Details attached in Annex 3. This considerable growth of medical colleges, particularly in the private sector inevitably raised concerns about quality, regulation and accountability. 13

PMDC, July 2009 GoP 2008 15 PMDC, July 2009 16 PMDC July 2009 17 PMDC July 2009 14

Similarly it has raised issues regarding faculty strength with the pace of production of high calibre teaching staff, particularly in specialist fields, unable to keep up with the growth of medical and dental collegesâ&#x20AC;&#x2122; requirements for experienced faculty staff. There is particular concern in respect of teachers and faculty staff for the basic sciences.

2.9.1 Production of doctors

In Pakistan medical education and the medical profession remains largely popular as a career and carries a certain level of prestige thus encouraging thousands of young people every year to pursue a medical education and ultimately for many a career in medicine and health care. There are annually an estimated 33,000 students who successfully clear the FSc. premedical examination in Pakistan and apply for admission to a medical college of which an estimated 3,500 are selected into public sector medical colleges18 and an estimated 2,500 into private sector medical colleges. Collectively this produces approximately 6,000 newly qualified doctors per year in Pakistan out of which an estimated 1,50019 emigrate. A large proportion never practice, particularly females. The exact figures for this are not known but estimates suggest that up to 70 percent of newly graduated female medical doctors never practice. Further attrition may be attributed to other causes such as death and illness. This reduces the actual number of doctors being added to the national overall total number of registered medical practitioners per year to approximately 4,300. Although reliable data is sparse of the estimated 26,000 students who are not successful in seeking admission to a medical college an estimated 80020, having the financial means, seek admission overseas, frequently China, the Philippines, former Soviet Republics, Malaysia, UK and USA. This is clearly a potential loss of health care professionals to Pakistan which also has its own financial loss to the country. Interestingly many of these overseas medical colleges are not recognised by the Pakistan Medical and Dental Council, the regulatory body for medical and dental colleges, and graduates are therefore not eligible to legally practice in Pakistan, a further loss. Each of the 27 medical training institutions in Punjab is attached to a teaching hospital. In total this provides places for a little over 2,000 medical students per year which in turn produces approximately 1,800 newly qualified doctors each year. For the year 2008 to 2009 2156 seats were available for first year MBBS students in Punjab. The same medical colleges offered a total of 2115 seats for the year 2006/7. Annex 4 indicates the allocation of seats for first year MBBS 2008-2009 in Punjab. 18

PMDC, July 2009 Talati and Pappas; Aga Khan University 2006 20 Scope of Medical Colleges in Private Sector; A.J.Khan 19

For the period 2009-2010 the final figure is still being considered however, it is likely to be a slight increase on the 2008/09 figure. This indicates a very small increase year on year to date. All doctors are required to register with the PMDC upon successful completion of their training.

TABLE 6: MEDICAL COLLEGES AND TRAINING INSTITUTIONS FOR DOCTORS IN PUNJAB21

TYPE OF INSTITUTION

NUMBER

Post Graduate Medical Institute

Institute of Public Health

University of Health Sciences

Medical Colleges ( public)

Medical Colleges (private)

Other Institutions (PIC, CH)

PHDC & DHDCs

Total

2.9.2 Quality assurance for medical education

The University of Health Sciences in Lahore has developed exacting standards to ensure transparency, uniformity and minimum standards in terms of medical education and transparency of selection and examination protocols for medical students, including entrance examinations for medical college, public and private; all entrance tests and medical examinations are now conducted through the UHS. Similarly the University of Health Sciences, Department of Medical Education has developed a programme of faculty development for medical colleges across the province. A number of faculty staff from each institute were selected and participated in a programme for the evelopment of â&#x20AC;&#x2DC;master trainersâ&#x20AC;&#x2122; skilled in modern teaching and assessment methodologies.22

Health Department Punjab 2009 UHS Dept. of Medical Education 2008

Nurses, Midwives and Lady Health Visitors 2.10 GENERAL OVERVIEW FOR NURSES, MIDWIVES AND LADY HEALTH VISITORS

2.10.1 Nurse Population Ratio The number of registered nurses in Pakistan has doubled in recent years and the ratio of nurses to population is now estimated to be one nurse to 3,626 per head of population. Similarly for midwives and Lady Health Visitors the numbers have shown improvement; one midwife to 53,882 per head of population and one LHV for 35,880 per head of population. 23 Still significantly short of recommended international standards but showing an upward trend. The nurse doctor ratio stands at 1 nurse to 3.5 doctors; this is in fact quite the reverse of WHO international standards which recommends 4 nurses to 1 doctor. 2.10.2 Number of Nurses

A total of 8921 nurses are working within the health sector of Punjab for a population of an estimated 90 million. There are currently 2061 LHVs practising at various levels of health care facilities in Punjab. It is interesting to note that a total of only 36 male nurses are working on regular contracts and on a contract basis as Charge Nurses in Punjab. Details Attached in Annex 5.

2.11 NURSING EDUCATION

2.11.1 Academic Programmes

Academic Programmes for Nurses Following basic and higher education professional training courses are available for nursing in Pakistan as indicated below:

Registrar, Pakistan Nursing Council March 2009



Basic Diploma, General Nursing: 04 years



Post Basic Diploma programme: 3 Colleges of Nursing are offering one year post basic diploma programmes in various specialities. These include but are not restricted to the following:        



Paediatrics Psychiatry Coronary Care Unit Accident and Emergency Ophthalmology Nursing Management, Ward Administration Neurosciences Nursing Education (Teaching and Administration)

Degree Programme Presently there are 3 degree programmes for nursing:  Post RN B.Sc Nursing: 2 years  Generic B.Sc Nursing: 4 years  M.Sc. Nursing: 2 years

Currently only five institutes in Punjab are offering BSc nursing and Post RN BSc nursing, producing less than 340 graduate nurses annually. Academic Programmes for Lady Health Visitors Candidates with 55 percent marks in aggregated science subjects in Matric are eligible to undertake the Lady Health Visitor course. Candidates with FSc Pre Medical with 50 percent marks are given preference. The age limit is 30 years. LHVs undertake a two year Diploma Course at the Public Health Nursing Schools. Currently there are 11 PHNS in Punjab. Examination is conducted under the Nursing Examination Board. The Pakistan Nursing Council is the regulatory authority which accredits the PHNS, issues a curriculum and registers the qualifying LHVs. Academic Programmes for Midwives The Pakistan Nursing Council recognises the following Midwifery Programmes Programme Pupil Midwife (PMW) Community Midwife (CMW) Diploma (RN RM)

Duration 15 months 18 months 12 months

Lady Health Visitor (LHV)

12 months

At present the midwifery programmes running in Punjab are discussed below: Nurse Midwives: All nurses undergo mandatory midwifery training during the fourth year of the General Nursing Diploma course. Community Midwives: A direct-entry midwife is being educated in the discipline of Community Health Nursing in 18 months. The Community Midwifery Programme does not require her to become a nurse. Direct-entry midwives are distinct from the nursing disciplines. The Community Midwife is trained to provide a ‘Midwives Model of Care’ to healthy women and newborns throughout the childbearing cycle primarily in out-of-hospital settings. Pupil Midwifery: This was also a one year programme that was being previously offered but due to a lack of planning and proper utilisation was suspended a few years ago. Traditional Birth Attendants: These are still the most opted non-formal midwifery practitioners in rural health care. TBAs are absolutely uneducated and non-trained. Many initiatives have been taken in the past to train these TBAs but due to one reason or another, none succeeded in achieving targets. 2.11.2 Nursing Training Institutions

Punjab has the highest number of nursing educational institutions as outlined in Table . The output of nurses is therefore higher in this province as compared to other provinces. On the contrary, Punjab has less than one fourth of the total number of nurses registered with the PNC, working in Punjab’s public health sector. This is indicative of the fact that despite having the highest output capacity, there is an absence of a well developed absorption plan for these nurses who are qualifying from these institutes every year.

TABLE 7: ACCREDITED SCHOOLS AND MIDWIFERY AND PUBLIC HEALTH IN PUNJAB

Punjab

School of Nursing 51

School of Midwifery 76

COLLEGES

Schools of Public Health 12

NURSING,

College of Nursing 3

Source: Pakistan Nursing Council, March 2009

Hence educating an increased number of nurses is not the only challenge, even if this increase occurs there is still insufficient numbers of nurses being employed to meet the needs of the health services. In the public health system this is due to an inadequate number of sanctioned posts. Although a one year Post Basic Diploma in Advance Midwifery has been initiated at JPMC Karachi and at the Khyber College of Nursing Peshawar, the launch of a similar programme is still awaited in Punjab. As shown in Table 8, various educational institutions in Pakistan offer nursing, public health and midwifery training for nurses, Lady Health Visitors and midwives respectively. Overall in Pakistan there are 141 midwifery schools however, there is not even a single College of Midwifery for midwives to further enhance their knowledge and move onto post graduation opportunities.

TABLE 8: ACCREDITED SCHOOLS AND COLLEGES OF NURSING, MIDWIFERY AND PUBLIC HEALTH IN PAKISTAN24

PROVINCE

SCHOOL OF NURSING

SCHOOL OF MIDWIFERY

SCHOOL OF PUBLIC HEALTH

COLLEGE OF NURSING

Punjab

Sindh

NWFP

Baluchistan

Total

109

141

Source: Pakistan Nursing Council, March 2009

2.11.3 Production of Nurses, LHVs and Midwives

In recent years, Pakistan has increased its nursing, health visiting and midwifery workforce production capability considerably. In the past ten years production of nurses has improved substantially.

Pakistan Nursing Council 2009

Three cadres of nursing personnel are trained in Pakistan as indicated above. Students of these schools are required to register with the Pakistan Nursing Council, as a registered nurse [RN], Lady Health Visitor [LHV] or registered midwife [RM]) upon successful completion of their training in accordance with the provincial nursing board examinations. The yearly output of nursing professionals in Punjab is as below:   

Nurses Midwives LHVs

: : :

2500-3000 1300-1800 700-900

2.11.4 Quality Assurance for Nursing Education

Pakistan Nursing Council is a regulatory body established in 1948 where only one nurse is working as a Registrar with eight supportive staff. Recently one Assistant Registrar has been appointed. A computerised registration system is functional with the assistance of a CIDA funded project since 1996. The Council is empowered by the PNC Act of 1973 to:             

maintain register for qualified nurses, midwives and LHVs develop and implement uniform regulatory mechanisms in education and services prohibit employment of unregistered nurses disqualify on account of mal-practices 26enalize fraudulent cases appoint office bearers submit annual report work with the Nursing Examination Boards for education and training develop and implement standards conduct inspections of educational institutions develop and implement uniform curricula develop mechanism of accountability and arrange general meetings of the Council.

Lady Health Workers 2.12 GENERAL OVERVIEW FOR LADY HEALTH WORKERS In 1993 the Ministry of Health, Pakistan and WHO jointly recognised that the very low utilisation rates of Basic Health Units, as low as 23 percent25 in some areas, coupled with shortages of professional health staff compromised the strategy of providing basic health care to community level. Being a signatory to the Alma Ata Declaration and committed to further developing and strengthening primary health care across the country and facing a shortage and imbalance of health care professionals, particularly in the rural areas Pakistan embarked upon a new programme of outreach at the community level in late 1993 when the National Programme for Family Planning and Primary Health Care – the Lady Health Workers (LHW) programme was launched26. The programme is funded by the Federal Government and cost effectiveness is a key parameter. To date it is estimated that the cost to the health department is approximately Rupees. 45/- per head of population. The annual salary cost of each LHW being around Rupees.45,000/-

Lady Health Workers Programme - two key objectives: 1. To provide low cost preventive and basic curative health care services ‘at the doorstep’ and 2. To provide employment opportunities for rural women

The Lady Health Worker is currently the only cadre of health care provider that is working at the community grass-roots level with good outreach, particularly to women and children. It is a vital cadre for addressing maternal, neonatal and child health in the community and to support the MDGs targets in MNCH. 2.12.1 LHW Population Ratio

The primary target was to identify, select and train 100,000 women, all local residents of the community in which they were to work, by 2005.

25 26

WHO WHO GHWA Case Study 2008

In August 2005 the Ministry of Health developed a revised plan to include expansion of outreach through to 2010. A new target of 110,000 LHWs was set; 30 percent coverage for urban areas and 90 percent for rural areas.27 Recognising the need to further expand the programme to cover all rural areas and urban slums a revised PC-1 developed in 2008/09, currently undergoing the approval process at the time of writing this report, will continue the expansion to cover 100 percent of the rural population and 60 percent of urban slums. Each LHW is responsible for around 200 households, an average of 1,000 people, and is attached to the local government health facility although actually working from her own home. One room in the LHW’s home is established as a ‘health house’. 2.12.2 LHW Production

There are currently 2,500 first level care facilities (FLCF) involved in the programme with 186 trainers at district level and 5,752 trainers at FLCF.28 The programme now covers all districts of Punjab and has almost 52,500 against an allocation of 57,381 trained LHWs and almost 2,000 LHWSs against an allocation of 2,295 across the province. The LHW is supervised by the LHW Supervisor who is typically responsible for 25 to 30 LHWs. 2.12.3 LHW Training

The training is spread over a period of fifteen months; the first three months is classroom based focusing on the prevention and treatment of basic common illnesses and some health education. This is followed by twelve months practical on-the-job training and experience coupled with additional classroom sessions. Each year the LHWs undergo refresher training for 15 days. In some cases, for example under the PAIMAN project LHWs receive training on additional topics such as counselling skills, use of IEC material and community IMNCI training and basic resuscitation for newborn care.

NPFFP&PHC Annual Report 2006 MoH, PHC Wing 2008

Paramedics 2.13 GENERAL OVERVIEW FOR PARAMEDICS With a scarcity of doctors and nurses in 1947 and a great need for the newly emerged Pakistan to rapidly expand health care services, particularly in rural areas, local dispensaries were established and rapidly expanded in number. These very basic health facilities were headed by Dispensers in turn supported by other paramedic staff. Thus began the extensive growth of the paramedic cadres offering basic health care in a number of fields including sanitation, leprosy, malaria and general public health. A recent study29undertaken within the framework of health sector reform in Punjab and part of the Punjab Devolved Social Services Programme, the ‘Restructuring of Paramedic Service Cadre in Punjab’, has highlighted the key issues and challenges in respect of paramedical staff and made sound recommendations for change, including a comprehensive restructuring programme to which the health department of Punjab has now committed and implementation strategies are being developed.

2.13.1 Numbers of Paramedics

Currently there are in excess of 40,000 paramedics of various cadres in the health department of Punjab. This far exceeds the number of nurse, LHVs and midwives combined. Working across 25 disciplines in both the clinical and public health field there are over 130 different categories of paramedics.

2.13.2 Production of Paramedics

Investment in the training and development of the various paramedic cadres has been minimal as compared to that of doctors and nurses. The extensive growth of medical colleges for example has not been paralleled by colleges for paramedics. The Punjab Medical Faculty, an autonomous body under the auspices of the health department, was constituted in 1982 to raise the standard of paramedic education. Similarly in 1990/91 the Government College of Paramedics Faisalabad was established to advance the various disciplines of paramedic’s education and further training. More recently in the public sector the AIMC has established the Institute of Allied Health Sciences specifically to train paramedics; this is still in process at the time of writing and 29

2009, PDSSP

likewise in the private sector the Fatima Memorial Institute of Allied Health Sciences. The educational requirement for these schools and other colleges for paramedic training is F.Sc. pre-medical. Regular, public paramedic training schools have been established in a number of DHQ hospitals across the province as indicated in Table 9. The minimum educational requirement for entry into these basic schools is matriculation.

TABLE 9: PARAMEDICS TRAINING INSTITUTIONS

NAME OF THE INSTITUTION

LOCATION

DISCIPLINES OFFERED

Government College of Paramedics

Faisalabad

2 year Diplomas;

Punjab Medical Faculty

Pharmacy; Physiotherapy; Nuclear Medicine; Dietetics; Public Health; Radiography; Operation Theatre; Dental; Medical Laboratory Lahore

1 year courses of nine standard disciplines; 18 months laboratory technicians course; 2 year dental hygienist; dietician and dental nurse

Paramedic Training Schools in DHQ hospitals

Jhelum, Sahiwal, Sargodha, Sialkot, Bahawalpur

1 year courses;

Nishtar Medical College

Multan

2 year dental nurse course (females only)

Mayo Hospital

Lahore

2 years Ophthalmic technician course

Al-Shifa Hospital

Rawalpindi

2 years Ophthalmic technician course

UHS

Lahore

B.Sc. Hon. & MSC all disciplines

(is the examination awarding body for certificates and diplomas of affiliated schools)

Laboratory Assistant; Sanitary Inspector; Operation Theatre Assistant; Radiographer

NUMBER OF SEATS

135

100 per school

FMH Institute of Allied Health Sciences

Lahore

B.Sc. Speech & Language Therapy ; B.Sc. Audiology; B.Sc. Dental Hygiene; B.Sc. Dental Technology; B.Sc. Optometry; B.Sc. Lab Technology; B.Sc. Physiotherapy; B.Sc. Medical Imaging Technology

HEALTH HUMAN RESOURCE PLANNING AND MANAGEMENT Key Challenges and Strategies SECTION THREE

3.1 GENERAL OVERVIEW

As seen from the current situation of the human resource framework in the Punjab health sector in relation to the six key cadres of health workers and indicated in Section Two the issues are multiple and various. Key challenges are complex, multifaceted and interrelated. These are further compounded by such issues as the changing burden of disease, demographics, relatively limited financial resources and socio-cultural influences. Most are inter-linked and mutually influencing. It is recognised that these also require an integrated and multifaceted approach for resolution. One key HR issue that has recently been addressed under the PDSSP is that of the development of job descriptions for all cadres of staff as listed in the MSDS report 1. This is noteworthy as many HR challenges link to job descriptions and roles and responsibilities therein. The real success of this initiative will be measured on the institutionalisation of the job descriptions and the regular review and updating of these as a key tool for recruitment and performance management. The job descriptions would also benefit from having more clarity regarding line management and management roles and responsibilities particularly as they provide the baseline for performance management. The next step would also need to address the development of personal profiles for each job description. Additionally a substantial piece of work has recently been completed also under the PDSSP on the restructuring of the paramedic service. The implementation of this revised service structure will significantly address the human resource issues associated with this cadre of health worker. Similarly in the MSDS report2 standard lists for human resources for each facility at primary and secondary levels have been reviewed and updated providing a sound basis for further HR planning within the health sector. This is a significant step forward and will contribute substantially to improving health care delivery once fully institutionalised and realised. For ease of reference the following section focuses on: 1. the more specific issues and challenges related to human resource planning, and management and grouped under one major challenge, the lack of a dedicated Human Resource Department supported by a well resourced HRMIS. This is applicable to all cadres and levels within the health department. Proposed strategies for improvement are indicated alongside each key issue. The key human resource challenges in respect of planning, management and development have been extrapolated from the analysis of the current situation in the Punjab health sector and summarised in Annex 6. 1

Job Descriptions; PDSSP, 2009 MSDS report, PDSSP; Contech International, 2008

3.2 ADDRESSING HUMAN RESOURCE PLANNING AND MANAGEMENT

Analysis of the current situation in respect of the key HR functions in Punjab indicates that standard protocols, policies and procedures that address human resource production, recruitment and retention, deployment, performance management, working conditions, professional development and promotion are not readily available. This is the root cause of many of the human resource problems presenting in the Punjab health sector today. Further the management and responsibility for HR planning, management and development are spread across and between departments with levels of authority ranging from district to DGHS and Secretariat as indicated in Section 2. This is creating administrative and bureaucratic challenges for all concerned. Moreover this dual system of management and control of health staff creates operational issues which impact significantly on the quality of health care service delivery. This has also resulted in varied interpretation and application of rules and regulations, diluted application of policies and procedures and an absence of reliable HR data for effective planning and management purposes. The development of a comprehensive health human resource framework that is required.

•

Systematically tracks supply and demand

•

Builds and operates reliable forecasting and scenario options with policy testing tools to help understand the issues and explore potential options and solutions

•

Has fully dedicated staff with HR qualifications and experience

•

Has relevant policies and procedures in place

•

Is well resourced

•

Has effective support mechanisms and

•

A well resourced HRMIS

It is recognised that this will take time and further study to develop, deploy and institutionalise.

3.2.1

Human Resource Planning

As part of the development of a dedicated HR department there is also a need to assemble and utilise HR projections into regular updated reports that are tested against outcomes and used as a baseline for planning and development. These are currently not available which is seriously compromising HR planning in the health department. It is recommended that this activity should be initiated in the short term rather than wait until the HR department is fully functional.

3.2.2

Human Resource Management

Similarly human resource management is largely seen as an administrative responsibility and the key HR functions are lacking in focus and application. The reader is also referred to Sections 5, 6 and 7.

3.2.3

Line Management

The unit heads of health care facilities, although technically in charge of the facility and all staff therein generally lack authority and clarity in this aspect of their role and responsibilities. The recently developed job descriptions3, an excellent and much needed initiative, would further benefit from more clarity in respect of the management role and responsibilities of all line managers within the health department. A serious gap is the lack of line management training for all line managers which should be a pre-requisite for a management post and should be completed at least within six months of taking up a managerâ&#x20AC;&#x2122;s post. Clarity on the levels of responsibility is also required. For example line managers should be involved directly in the recruitment, posting, performance management and promotion of all staff who report to them. Frequently this responsibility is somewhere much further up the line; too far removed for the decisions to be grounded in reality. Similarly staff are often unclear as to who is actually their line manager and many often bypass the immediate line manager when seeking promotion, support or information. Hence very senior staff, at times even at the secretariat level, are over-burdened with requests for transfers, promotion and completion of ACRs. There exists a perception that the line manager may be unreliable, un-willing or unable to complete the routine tasks of line management; levels of trust are often compromised. These issues are further compounded by the fact that delegation of people management in the true sense is missing; delegation is incomplete without the delegation of authority and 3

Job Descriptions and Performance Evaluation Criteria; PDSSP 2008/9

resource management to support all actions. Such is the situation with people management in the health sector. The mid-level line manager in particular generally lacks the real authority and the resources to manage her/his team effectively.

3.3 PROPOSED KEY STRATEGIES – HUMAN RESOURCE FUNCTIONS

Key Challenge: lack of effective human resource planning and management The key objective is to develop more effective, comprehensive human resource planning and management systems and protocols

Short to Medium Term: 

a study/audit of the current human resource functions to set benchmarks and scoping for the strategic development of a Human Resource Department



development of a comprehensive fully resourced human resource department at provincial level with semi-autonomous units in each district



development of HRMIS at provincial and district levels



development and institutionalisation of mandatory management training for line managers

Key Challenge: lack of appropriately qualified staff for new HR departments

Short to Medium Term:   

train key HR staff to be deployed to the new HR Department; develop a training plan for key HR staff; identify training opportunities develop and implement on-going CPD programmes for all HR staff develop and institutionalise refresher training for all line managers

3.4 DEVELOPMENT OF A HUMAN RESOURCE DEPARTMENT

To address the magnitude and complexity of the human resource issues currently facing the health department in Punjab, the key recommended strategy is to establish and resource a fully functioning human resource department within the health system at provincial level with linked semi-autonomous units at district levels.



HR planning, management and development



Recruitment and posting practices



Succession planning



Disciplinary procedures



Grievance procedures



Compensation and reward protocols



Performance management systems



Career structures and promotion protocols



Staff development



Health and safety



People-friendly support and guidance

For this to be truly effective each unit and the provincial department must be linked by a HRMIS computer data base with skilled operatives and supporting resources. The development of such a department, organised by function, would work in such a way that will best support the overall goals and aspirations of the health department at each level. This department would be dedicated to providing and maintaining effective HR policies and procedures covering all disciplines including: Additionally, the human resource department would serve to ensure that the organisational mission, vision and values are maintained and organised towards optimal success. It is further recommended that the newly established HR department should be reviewed after three years as is the normal practice in modern organisations. Adaptations may be minor or a significant overhaul may be required. This exercise should be included in the annual planning process and budgeted accordingly.

3.4.1

Options for the Development of a Human Resource Department

There are two main options for this extensive, strategic exercise: 1. Engage a specialist company and outsource the architectural design and development of a fully functioning HR Department within the health sector who are also tasked to provide on-the-job learning for a HR team. Meanwhile key personnel would undertake post graduate training in various HR specialities 2. Develop the department using short and medium term technical assistance and dedicated health department staff working together while recruiting and training key personnel who would eventually take over all functions

The first option is likely to be more efficient and proactive but may lack ownership. The second option is likely to take more time, be less efficient but ultimately have more ownership and thereby be more effective in the longer term. A third, but perhaps less popular option with the health department could be that the total HR function is fully outsourced to a specialist company taking lessons from the corporate sector. In this way the health department would not have the day-to-day responsibility of the HR functions thereby removing a considerable load from already overworked departments. Once policies and frameworks were agreed the implementation and follow up would be the responsibility of the company. Key senior staff within the health department having HR qualifications would act as liaison managers. Annex 7 indicates a proposed model for a Human Resource Department 3.4.2

Development of HRMIS

It is recommended that in order to progress the development of a dedicated HR Department within the medium term the simultaneous development of a comprehensive data base, HRMIS, would also be required. Outsourcing would be the best option for the development of the system. Alternatively, technical assistance could be assigned to work alongside IT specialists. A model would be developed according to need and best practice and maintenance contracts should be agreed for the long term technical management and maintenance of the system. 3.4.3

Audit of HR Functions

It is further recommended that an audit of the current human resource function is first undertaken to set benchmarks and scoping for the strategic development of the Human Resource Department. This will ensure that all aspects of human resource planning, management and development are included and all key HR functions provided for. Modifications and additions could be made to meet increasing and changing needs and emerging best practices after a three year review.

3.4.4

Training of Key Staff to be deployed in the HR Department

Simultaneously it is recommended that staff should be recruited and trained in the human resource disciplines with separate sections established within the overall department to focus on the various aspects of human resource planning, management and development. These staff must be human resource specialists rather than doctors, general managers or administrators. The disciplines of human resource are distinct and require people with appropriate qualifications and experience in each particular field.

Lessons and models may be taken and adapted from corporate sector organisations at the cutting edge of managing and developing human capital. International options for post graduate training in the HR disciplines may be explored with various universities and the Institute for Personnel Development in UK

3.4.5

Proposed Staffing for the Human Resource Department

Given the magnitude of the health department and the complexity of all the HR functions the minimum staffing requirements at a senior leadership level would require a Human Resources Director supported by Deputy Directors for Human Resource Development, Human Resource Planning and Human Resource Management respectively at the provincial level. These would in turn be supported by senior human resource generalists, computer operators for data entry and management and assistant human resource officers who would be given career development and progression opportunities for succession planning and further strengthening of the department in the longer term. A suggested organogram is attached as Annex 8. This model would simultaneously be further replicated at district level with some adjustments according to the size, staffing levels and complexity of the districts. In smaller districts, clearly a smaller department would be envisaged. District HR audits should be undertaken to determine this need rather than apply a ‘one size fits all’ approach.

KEY OBJECTIVES OF THE HUMAN RESOURCE DEPARTMENT 

To assess and meet the human resource requirements of the Punjab health department to meet the Minimum Service Delivery Standards and the MDG targets 

To ensure that effective, transparent and efficient HR policies and procedures are in place and adhered to



To achieve optimal utilisation of all health care personnel for the achievement of quality service delivery



To ensure the availability of suitably qualified people across all levels of health care provision and education



To support the Punjab health departments commitment to the Health System Reform Programme by ensuring implementation of all new and approved HR frameworks e.g. paramedics restructuring



To plan for and incorporate human resource development as an integral component of the HR strategy

HEALTH HUMAN RESOURCE DEVELOPMENT: Key Challenges and Strategies

SECTION FOUR

4.1 GENERAL OVERVIEW OF HEALTH HUMAN RESOURCE DEVELOPMENT

Human resources play a crucial role in delivering health care services. Health planners and decision makers have to ensure that the production and capacity of health personnel in the right balance is available at all times to meet the requirements of an ever changing health environment. In the context of the MDGs, human resources represent the most critical constraint to achieving targets. Therefore it is fundamentally important for health planners and decision makers to identify the level and mix of health human resources that are required to meet the MDG targets. Human resource development is one of the key functions within the overall framework of human resource planning and management. Planning health human resources is a complex and multifaceted process involving several different cadres of health workers and different levels of technical skill. It needs to consider both the technical aspects of estimating and forecasting the numbers, skills and distribution of health personnel required to meet the health needs of the population and the political implications, values and choices of the government health policy within given resources. In the developed world, human resource development has evolved from an emphasis on increasing numbers to improving quality. Gradually, attention has moved towards improving education, skill enhancement, utilisation, efficiency, quality assurance and effective planning. Human resource development has three major components1: a. planning b. production c. management These three components function in an ongoing cyclical process and must be evaluated and updated regularly rather than merely in times of crises2. Additionally human resource development includes the maintenance of a skilled workforce through continuing professional development, continuing medical education, in-service training and general updating of all health personnel. The HHRD planning component is concerned with the process of estimating the number of health personnel and the kind of knowledge, skills, and attitudes they need to achieve predetermined health targets3. Other dimensions of HHRD planning include:

Becchus, 1991; Hall & Majia, 1978; Keet, Henley, Power, & Heese, 1990; WHO, 1990 Birch, Lavis, Markham, Woodward, & Oâ&#x20AC;&#x2122;Brien-Pallas, 1994; Kolehmainen-Aitken, 1993 3 Hall & Mejia, 1978 2

      

examination of current supply and demand demographics of current health personnel burden of disease population demographics; cultural context geographical distribution level of care (primary, secondary, or tertiary) filled and vacant positions

The overall purpose of human resource development planning is to identify and achieve the optimal mix and distribution of personnel at a cost which society can afford4 . Moreover, it not only deals with numbers but is concerned with having the right people in the right place at the right time, all doing the right things and having the right level of expertise5 .

4.2 LACK OF RELIABLE DATA FOR PLANNING

Realistic and consistent data are required to form the basis and rationale for planning and implementing health human resource activities. Without up-to-date, relevant data it is extremely challenging for any organisation to effectively undertake human resource planning and forecasting. A major issue in health human resource planning and development in Punjab is the lack of a reliable, consolidated description of the employment situation of public and private sector health personnel, including doctors, nurses, paramedics, lady health visitors, and midwives. In the public sector, although there may be data concerning the number of sanctioned posts in all federal and provincial jurisdictions as approved by the respective government, reliable information about the employment of health personnel filling these posts is not available. In the case of nurses for example there is reason to believe that many of the senior sanctioned posts in the health department, although approved for nurses, are being filled by non-nursing personnel6. Information essential for effective human resource planning, if available, is piecemeal, not consolidated in one area and very difficult to access in most situations. This unavailability of readily accessible, comprehensive human resource data in the province has caused, and continues to cause, numerous problems in planning for human resource development to meet the current and future requirements of the health care delivery system. There is a complete lack of any form of HRMIS within the Punjab health care system. In the absence of such key data there is no foundation on which to base future projections and forecasting for the production and deployment of health personnel. 4

Kazanjian, 1991 CHEPA, 1995 6 Amarsi, 1998 5

4.3 HEALTH HUMAN RESOURCE DEVELOPMENT â&#x20AC;&#x201C; CURRENT SITUATION IN PUNJAB

Human resource development encompasses all aspects of learning and development of people. It is a broad term and includes continuing professional development, continuing medical education, in-service training and other development activities such as on-the-job learning, study visits, exchange programmes, participation in seminars and self-directed learning. All of these options need to be employed to provide a comprehensive programme for human resource development and it is strongly recommended that an imaginative combination be considered in the long term for the continuing development of all health professionals in the Punjab health department. Such initiatives need to be linked to promotion, reward and recognition packages and performance management. One key outcome of performance management would be an individual learning and development plan. The implementation of this would be reviewed annually as part of the performance review process.

4.4 E-LEARNING

The use of e-learning for continuous professional development and in-service training is still in its infancy in Pakistan and to date has been slow to keep pace with international trends in this field. There are now encouraging signs of progress in this regard and some innovations are taking place within the more progressive medical colleges and post-graduate institutions.

4.5 IN-SERVICE TRAINING In-service training, short courses and workshops may also contribute to the on-going development of medical staff, however, the quality and nature of this is questionable and the long term benefits may fall well short of the envisaged outcomes. There are some exceptions of which â&#x20AC;&#x2DC;Integrated Management of Neonatal and Childhood Illnessesâ&#x20AC;&#x2122; (IMNCI) training may be one; this is largely undertaken through the support of donor agencies. Evidence indicates that overall in-service short courses fail to deliver significant improvement in performance back in the work place. Overall, the quality and focus of in-service training needs to be improved in accordance with minimum standards. The mechanism for delivery of in-service training would also benefit from further review. 43

4.6 PROVINCIAL AND DISTRICT HEALTH DEVELOPMENT CENTRES

The Provincial Health Development Centre was established under the Second Family Health Project in 1994. The PHDC succeeded the Management Training Institute for Doctors with an expanded role. It was intended to be a centre of excellence for analytical and development work and to support CPD through in-service training programmes for health staff. A network of 31 District Health Development Centres links to the PHDC. Although considered an attached institution of DGHS, the later has neither any role in prescribing the contents of training programmes of PHDC, nor does it performs any supervision of the training quality. This network of PHDC and DHDCs needs to be reviewed and revitalised including provision of adequate resources and qualified teaching staff. SUMMARY OF THE KEY CHALLENGES – EDUCATION AND TRAINING        

Outdated curricula for professional training and education Lack of standardisation and regulation across public and private sector training institutions Deficiencies in faculties strengths and capacities Lack of a qualified teaching cadre Lack of an independent monitoring and evaluation system for training and education Absence of career counselling for students and parents Lack of leadership development programmes Professional development, HR development, not planned or need based

4.7 PROPOSED KEY STRATEGIES – HUMAN RESOURCE DEVELOPMENT

Key Challenge: professional development, HR development, is not planned or need based The key objective is to have a well planned, productive workforce to meet the health needs of the population Short Term:   

review existing training and HRD protocols review the PM protocols to include learning and development plans link to the development of a fully dedicated HR department as indicated in Section 3 44



develop training opportunities to include interpersonal communication and behavioural skills to build staff confidence and effectiveness

Medium Term:      

HRD plans developed and linked to performance management needs assessments may be required as an interim strategy to develop HRD plans for units and facilities develop district HRD plans conduct a review/study to determine actual need for in-service training and training type conduct a review/study to determine actual need for additional professional qualifications to support promotion mechanisms develop programmes according to need

Long Term:    

all key health staff to have Learning and Development plans as an outcome of performance management and HRD planning processes institutionalise HRD plans formulated from individual L&D plans in-service training to be based on actual needs and HRD plans institutionalise CPD with minimum standards and requirements for promotion

Key Challenge: Continuing Medical Education largely inadequate; no standard mechanism Short Term:      

accreditation programme to be initiated by UHS in 2010 to be further expanded minimum standards to be set/reviewed in accordance with regulatory bodies plan for strengthening of all faculties develop credit systems for standard continuing education to enable students to study flexibly towards further professional qualifications use secondary care facilities for post graduate placements; rotational options promote quality research as a basis for action

Medium Term:      



strict adherence to regulatory bodies requirements for standards in CME review existing CME opportunities and standards explore option for further expansion of e-learning opportunities further strengthen existing CME programmes and regulation introduce new CME programmes according to needs implement alternative study options for CME i.e. self-directed learning; distance learning; links to international institutions for distance learning supported by videoconferencing use of quality research to further strengthen systems

Long Term:      

CME mandatory for promotion and continuance to practice CME mandatory for renewal of registration to practice institutionalise alternative study options institutionalise credit based learning introduce coaching and mentoring options for staff development develop a research culture as part of CME; number of publications, research reports mandatory for promotion of teaching/faculty staff

Key Challenge: standard, quality and appropriateness of in-service training Short Term:  

    

re-define and further strengthen the role and network of DHDCs and PHDC to provide quality in-service training and induction programmes according to need undertake a needs assessment for the development of a minimum package of inservice training and induction programmes using job descriptions and role requirements initiate training for trainers in modern teaching and learning methodologies and classroom management discontinue poor quality ad hoc in-service training that is not need based identify external institutions and specialist organisations to support CPD/HRD activities based on need use HRD plans as a basis for in-service training plans induction programmes to be developed for all new staff; DHDCs to implement

Medium Term:       

review and update minimum package for in-service training through PHDC and DHDCs; link to promotion requirements continue to train and update trainers and facilitators for in-service training in modern learning management explore new initiatives for CPD i.e. e-learning; self-directed learning develop ‘back to work’ orientation programmes to be conducted through the DHDCs and PHDC institutionalise ‘back to work’ orientation programmes for all key cadres develop training packages to be delivered by specialist organisations i.e. leadership development programmes; emergency response programmes training to be based on HRD plans; need based

Long Term:   

develop alternative packages for learning opportunities institutionalise alternative learning opportunities induction and ‘back to work’ programmes institutionalised

Key Challenge: lack of quality research; research culture not seen Short Term: 46

  

use existing institutions to undertake reviews and ‘research’ of areas outlined in this study explore options for establishing research as mandatory for senior teaching and faculty staff amend service rules and regulations accordingly

Medium Term:  

develop a culture of research in all post graduate educational facilities based on real need utilise research findings to further improve systems and mechanisms

Long Term:  

research mandatory for all senior faculty staff; service rules amended to reflect this annual budget allocations for research

4.8 BUILDING FACULTY STRENGTH

It is recommended that a review of faculty’s strengths for all cadres be undertaken by an independent third party to assess the full situation and recommend further action. Minimum standards should be developed and implemented according to each institution. Standard levels of teacher student ratios should be set and similarly minimum qualification requirements for teaching staff. Teaching staff should be qualified in modern teaching and learning methodologies in addition to classroom management and student support. Incentives and increments in basic pay are recommended for the recognition and reward of post graduate qualifications and consistently good performance for faculty staff. Promotion of teaching staff must be linked to continuing professional development e.g. a minimum number of hours per annum with evidence and recording mechanisms.

4.9 LEADERSHIP DEVELOPMENT

It has been observed and documented widely that having the right leadership in place is tantamount to successful implementation of organisational goals. The development of effective, visionary leaders is much required in the Punjab health department. Other than one or two management development programmes there is a total absence of leadership development within the Punjab health department. It is strongly recommended that further attention be given to the development of a leadership programme for senior managers (leaders) i.e. EDOs, Programme Directors, hospital managers. Phased over a three year period all senior managers should undergo leadership development training as a requirement for professional and career development and a prerequisite for promotion into higher senior positions. 47

It is further recommended that management development programmes also be initiated and institutionalised for senior level managers i.e. unit heads of health facilities, Project Managers, as a pre-requisite for promotion to a senior manager post. The leadership and management development programmes would be highly interactive, scenario based programmes undertaken off-site with a high ratio of facilitators to students and group size not exceeding eight to ten. Programme development would benefit from being out-sourced to a specialist leadership development company or group of specialists. The programme must be tailored to the context and need of the health department.

4.10

PROPOSED KEY STRATEGIES – LEADERSHIP DEVELOPMENT

Key Challenge: lack of leadership development Short Term:   

explore the possibilities and options for leadership development programming identify a company or persons to develop the programme develop an implementation plan

Medium Term:       

hold the first LDP for key senior managers (leaders) fully review the successes and challenges of the programme and revise accordingly initiate the training of LDP facilitators for independent continuity of the programme complete the first phase of LDP evaluate the impact develop a first phase SMDP review and adapt the SMDP

Long Term:     

adapt and modify the LDP institutionalise LDP for all senior managers as a pre-requisite for promotion institutionalise SMDP for all mid level managers as a pre-requisite for promotion to a management post continue the cycle of review and impact assessment and modification develop and implement follow up programmes

A phased approach to improved staff development is recommended to meet staff and organisational needs. Special attention needs to be given to the development of qualified teachers and facilitators as a matter of priority.

Doctors 4.11

CME & CPD OF DOCTORS- CURRENT SITUATION IN PUNJAB

An additional factor that relates to the other key HR functions of retention, performance management and promotion of doctors in the health care system in Punjab is that of continuing medical education and continuous professional development. Overall this is relatively weak in spite of having a number of well established institutions and facilities in the province. There is no requirement to re-register with the PMDC on an annual basis and there is no requirement to undertake additional learning, CPD or CME to continue clinical or teaching practice. At the faculty level there are fewer teachers available than required especially in the public sector and most do not have a recognised teaching qualification; this is not a pre-requisite for a teaching post. With the growth of the private sector in medical education many public sector faculty staff have moved to the private sector enticed by the salary e.g. public sector salary is around Rupees 80,000; private sector around Rupees 200,000 per month.

4.12

ANALYSIS

4.12.1 Teaching Qualifications Previously faculty staff were selected through a selection committee process and the person deemed to be the most appropriate by the selection committee was appointed. This has not been the practice since 1995. Most appointments into the teaching cadre appear to be made without due process; merit does not seem to be the key determining factor. Similarly teaching staff once appointed may or may not receive in-service training on modern teaching methodologies, learning management or student support mechanisms. For those that do it is likely to be just two to three days in-service workshops. Doctors in the teaching cadres are becoming increasingly demoralised due to poor pay, even with teaching allowances, lack of access to cutting edge information, including IT and on-line learning opportunities and lack of a professional career pathway or promotion structure supported by professional development. 4.12.2 Continuing Medical Education Previously CME had to a large extent been influenced and in many instances led by pharmaceutical companies, which in itself raises issues regarding objectivity and ethics. With 49

the changing global financial situation and the security situation in Pakistan the practice of bringing in overseas speakers and sponsoring large seminars and workshops has now declined significantly. CME opportunities of this nature have declined over the past three to four years. CME generally refers to the continuing development of practicing doctors, largely in clinical skills but not exclusively. It is recommended that the more traditional forms of CME, lectures and classroom based didactic teaching be replaced by more interactive, modern approaches to learning based on learning outcomes and practical application. This should increasingly include e-learning, video-conferencing and self-directed learning and practical experience which could be through exchange visits, short-term secondments and job rotations. Punjab does have a considerable number of institutions offering CME of various types as indicated in Table 10

TABLE 10: INSTITUTIONS OFFERING CONTINUING MEDICAL EDUCATION

NAME OF INSTITUTION University of Health Sciences

Institute of Public Health

College of Physicians and Surgeons Punjab

COURSES OFFERED PH.D (over 16 disciplines) M. Phil (various disciplines) Post graduate research opportunities Post Graduate Medical Diplomas (12 disciplines) M.Phil. Programme in Basic Medical Sciences (10 disciplines) Masters in Public Health (Gen) Masters in MCH Masters in Hospital Management M.Phil. Hospital Management FCPS (various specialties) MCPS (various specialties) DCPS (various specialties)

Armed Forces Post Graduate Medical Institute

4.13

4. 13 UNIVERSITY OF HEALTH SCIENCES

The University of Health Sciences, Department of Medical Education in Lahore supported by a variety of both national and international specialists has in recent years launched several new courses for CME including post graduate diplomas7. More recently a new subject of Behavioural Sciences has been introduced into the curriculum of all Medical, Dental and Allied Health Sciences programmes at both undergraduate and post graduate level8.

7 8

UHS Lahore; 2008 UHS Lahore; 2008

Also, the Department of Medical Education, with the support of relevant subject specialists from affiliated medical institutes and the Higher Education Commission Foreign Faculty, is currently working on the development of curricula for postgraduate clinical sciences in different Master of Surgery (MS) and Doctor of Medicine (MD) programmes.

4.14

ACCREDITATION OF CONTINUING MEDICAL EDUCATION

In a new initiative to bring quality and standardisation across the sector the UHS has proposed an accreditation of CME programmes across Punjab, to be expanded to include the whole country in due course. It is anticipated that this will be initiated from 2010 onwards. Under this initiative the CME provider will apply to the UHS for accreditation. This will involve an initial registration fee of Rupees. 5,000/- and an accreditation fee of Rupees. 20,000/- per year. The Department of Medical Education has now also initiated a CME programme which is flexible and promotes the concept of continuing professional development in such areas as research and proposal writing. Additionally, WHO9 is actively supporting initiatives with the health department in Continuing Medical Education working with national collaborating centres, spearheaded by the College of Physicians and Surgeons Pakistan with the objective to establish CME as a requirement for the continuing registration of doctors and other health professionals. In conjunction with this the health department has established strategic guidelines for CME until the day it becomes a requirement for the registration of health professionals; this is a significant step forward. Much remains to be done to make this a reality.

4.15

THE COLLEGE OF PHYSICIANS AND SURGEONS PAKISTAN

The College of Physicians and Surgeons Pakistan, a post graduate training institute having regional centres across Pakistan, including five in Punjab, offers post graduate training in medical sciences in 53 specialties with sub-specialities in FCPS and Membership (MCPS) in 18 disciplines together with a two year college diploma, DCPS, which is being offered in 14 disciplines. The duration of the FCPS training varies from four to five years depending upon the specialties chosen. Competency based curricula have been developed for each discipline by the relevant faculties. More than 10,000 training seats have been awarded in 129 CPSP accredited medical institutions throughout the country. The College critically evaluates the standards and facilities available in these institutions to ensure quality training for its trainees.

WHO 2004

Similarly, there are a number of other institutions, largely situated in Lahore, both public and private, providing post graduate training opportunities including the medical colleges. One issue is the limited funding available for the number of potential candidates to take up post graduation seats in the teaching hospitals. This is compounded by over-stretched faculties in many institutions, lack of a dedicated teaching cadre and dedicated clinical instructors.

4.16

COMMUNITY ORIENTED MEDICAL EDUCATION

An additional relatively new concept is that of Community Oriented Medical Education (COME) being promoted by WHO, primarily to promote and support revisions in medical curricula to include public health thus producing medical graduates more professionally equipped to meet basic primary health care needs of the population. This has been reviewed and in principle agreed by the PMDC and the health department but has yet to be rolled out in a systematic manner.

4.17

MANAGEMENT QUALIFICATIONS

Of particular concern is that of the administrative cadre of doctors. Some doctors in administrative posts have a relevant post graduate qualification such as an MBA, MPA, MHA to support their promotion or posting into the administrative cadre. For the most part doctors promoted into the administrative cadre are not trained in public administration or modern management disciplines leaving them ill-equipped to undertake their roles and responsibilities with any degree of confidence or success. The choice of a public health qualification for administrative cadres is not sufficient to equip doctors to deal effectively with all the administrative and management responsibilities that are expected from that senior role. The outcome of this is fourfold: 1. staff who are frustrated as they do not have the skills for the job; or frustrated in that having a public health qualification, MPH, they are managing a basic health facility and thereby not utilising their qualification as they had expected 2. poorly managed health facilities, especially at the tertiary level where the skill gap is most profound 3. de-motivated staff who are inadequately managed and supported 4. high levels of absenteeism and lack of accountability due to weak management and poor application of key HR protocols

4.18

PROPOSED KEY STRATEGIES – EDUCATION AND TRAINING

Key Challenge: outdated curricula; not in line with current needs The key objective is to improve the quality of education and training at all levels Short Term:   

audit of the status of current curricula review and updating processes particularly for nurses, doctors and paramedics assessment of further input required into curricula updating provision of required support for curricula updating

Medium Term:       

updating of curricula approval of updated curricula by regulatory bodies; accreditation training of faculty staff and teachers in new curricula implementation of updated curricula provision of support materials for updated curricula establish and institutionalise a regular review of curricula through a standardised procedure develop and institutionalise monitoring and evaluation mechanisms for all educational and training institutions across Punjab

Long Term: 

regular review and further updating of key curricula by authority/accreditation bodies

Key Challenge: Lack of standardisation and regulation Key objective is to standardise and regulate training and education to ensure quality and regulatory mechanisms Short Term:    

review of regulatory framework for quality training standards upgrade and strengthen the regulatory framework through one awarding agency; UHS accreditation; (this is proposed to commence from 2010) development of minimum standards where none exist strict application of PMDC standards

Medium Term:    

implementation of accreditation processes for all training and education in health implementation of minimum standards for training development of modern question data banks based on revised curricula extension of accreditation process for CME to all training institutes as a requirement to offer training and CME 53

Long Term:  

monitoring of accreditation process monitoring of quality standards in training

Key Challenge: deficiencies in faculties The key objective is to further improve the quality of teaching and learning at all levels Short Term:  

   

undertake a review and practice audit of faculties in key institutions establish minimum faculty levels as a prerequisite for accreditation; minimum standards for student teacher ratios in classroom and practical based learning environments initiate faculty development and evaluation protocols promotion of teaching staff to be linked to evidenced CPD assess training needs of existing faculty staff explore options for a recognition and reward system for faculty staff based on performance and qualifications

Medium Term:      

build faculty strength through new recruitment as required based on need and minimum standards build capacity of existing faculty members through professional development programmes strengthen existing faculties before establishing new institutions CPD established as a requirement for all faculty staff publications and research papers mandatory for senior level teaching staff implement a recognition and reward system; incentives for faculty staff

Long Term:  

minimum hours of CPD mandatory for all faculty staff to continue practicing minimum research and publication requirements established

Nurses, Midwives and Lady Health Visitors 4.19 PRE-SERVICE AND IN-SERVICE TRAINING OF NURSE PROFESSIONALSCURRENT SITUATION IN PUNJAB

Continually improving skills, knowledge and experience is essential in todayâ&#x20AC;&#x2122;s rapidly changing health care environment. Continued professional learning and development through well developed in-service training programmes for nurses, LHVs and midwives is lacking in Punjab. This is essential to have in order to help them do their job efficiently and effectively and assist them in pursuing their career goals. 4.19.1 Poor Quality of Nursing Education Problems are also experienced in nursing education which ultimately affects the quality of nursing care and ultimately the overall health care delivery in the country. Since nursing personnel are critical to the delivery of health care, a clear definition of the present nursing workforce will facilitate more effective and efficient future health care planning policy development. 4.19.2 Nurse Faculty A critical shortage of trained faculty in most of the nursing institutions is yet another complicating factor as highlighted in Table 11. For the 4576 nursing students enrolled in the General Nursing Diploma Programme, 1336 in the Nurse Midwifery and 1251 in the Community Midwifery Programmes, the total sanctioned posts for Nursing Instructors is 281. Out of these 90 are lying vacant.

TABLE 11: EXISTING TEACHING STAFF AND ADDITIONAL REQUIREMENT ACCORDING TO PAKISTAN NURSING COUNCIL

Total Stipend Seats (General Nursing + Midwifery +

Total Sanctioned seats of Nursing Instructors

Filled

Vacant

Requirement according to PNC criteria (2 Nursing Instructor for 25 Students)

Additional requirement (on present stipend strength)

Pupil Midwifery) 6129

281

191

490

490 â&#x20AC;&#x201C; 281= 209

Details of current status of faculty strength in Schools of Nursing in Punjab are attached as Annex 9. Keeping in view the nursing faculty shortage, the Government of Punjab entered into a Public Private Partnership with the Saida Waheed FMH College of Nursing for an output of 60 BScN and 60 Post RN BScN qualified nurses per year. The creation of sanctioned posts and an effective absorption plan for the degree holders is still not in place to utilise this faculty output. Only the University of Health Sciences has initiated a Masters programme for nurses but that is also in the absence of full time faculty. Out of a total of eight nurse PhD. holders among nurse professionals, not even one is working in Punjab; seven are located in the AKUSON and one in AJK. There is no higher qualification programme available for midwives and LHVs in the country. Keeping in view the challenges and demands of modern health care the nurses with higher academic qualifications are required. Entry point for nurses needs to be raised to a Bachelor Degree Level in due course of time. The major challenges facing midwifery is the shortage of faculty for proper training of midwives and the need for a proper education structure. Some of these courses accept students for a one year program and accord registration at the age of even 16 years which is too young an age to handle a midwifeâ&#x20AC;&#x2122;s responsibilities effectively. This results in poor quality care of mother and the baby. Also at this young age these midwives experience problems of safety and security at their workplace.

4. 19.3 Inadequate Nursing Human Resource Development Human resource development has been the most neglected factor in the process of economic development in Pakistan. There has been persistent, inadequate nursing human resource in the country for the past five decades and the demand for nursing personnel continues to increase. There is a need for effective strategic planning for their development and their recognition as well as their inclusion in overall health planning and policy development. Prior to the development of any provincial health human resource plan the first stage should be to improve understanding of the current situation. Development of a comprehensive human resource database, HRMIS, is necessary as indicated in Section 3 before any planning process can begin.

4.19.4 Rising Demand for A Better Planned Nursing Human Resource In Punjab The factors influencing the increased demand for a better planned nursing human resource in the country are10:     

the rapid population growth, advances in health technology, shifts in patterns of diseases, rising social expectations and rapid growth of the health industry

4.19.5 Lack of appropriate Leadership in the Nursing Sector The roles of nurses consist of providing care to individuals, groups, families, communities and populations in a variety of settings. Leadership is an essential element for high-quality professional practice environments in which nurses can provide high-quality nursing care. Unfortunately the nursing profession in Punjab lacks strong, consistent and knowledgeable leaders, who can inspire others and support professional nursing practice.

4.20 NURSES IN-SERVICE TRAINING INSTITUTIONS

4.20.1 Post-graduate College of Nursing The College was established in 1988 with the following objectives: 

Educate nurses to provide exemplary nursing care appropriate to the health needs of the individuals, families and communities in variety of settings;



Provide leadership in nursing education, practice administration and research;



Provide resource centre for continuous education, which will meet the present need of society providing quality care nursing; and



Prepare expert nurses in various specialised disciplines.

The College is under the direct administrative control of the Secretary Health.

4.21 ANALYSIS OF PRE-SERVICE AND IN-SERVICE TRAINING

4.21.1 Education of nurses, LHVs and midwives Schools of Nursing, Midwifery and Public Health are being established without adequate numbers of qualified faculty. The student/qualified teacher ratio is also not appropriate. The curriculum is not competency based and students have insufficient supervision in clinical practice. Basically, nursing, health visiting and midwifery education institutions are under10

Green , 1995

resourced to deliver existing programmes, Nurses have little opportunity for continuing education after graduation. LHVs and midwives are still awaiting initiation of a degree programme in their field. LHVs are keen in advancing their career in the same field but due to lack of any in service training programmes, there is little that they can do. Some move on to nursing after doing four years General Nursing Diploma. There is a need to provide refresher courses for those LHVs who have been away from work for more than two years. This will contribute towards addressing the shortage of LHVs. It is also essential to initiate Bachelors Degree Programme for LHVs to provide opportunity for enhancing their knowledge. The Community Midwifery Programme is being run at the District Level by MNCH, PAIMAN, UNICEF, UNDFP, in Schools of Midwifery. There is no in-service training programme for the midwives. Recently Saida Waheed FMH College of Nursing took the initiative of running a capacity building programme for midwifery tutors in collaboration with the Amsterdam Midwifery Association. 4.21.2 Training for Leadership and Management Skills Development Currently Pakistan is producing nurses with degree level qualification, but they have few opportunities to actualise their full potential and provide input into strategic policy decisions. There are few formal programmes in Pakistan to educate leaders and when they attain leadership skills there are few positions within which to use these skills. Where these positions exist they are at times filled by medical doctors. SOHIP has taken the initiative of developing a comprehensive Nursing Leadership Programme for the senior nurse professionals. This programme however, needs to be instituionalised and linked to career development of senior nurse professionals. LHVs and midwives have no such training programmes available for their capacity building. 4.21.3 Comprehensive in service training plan Training needs of nurses, LHVs and midwives are not being formally analysed. The formal and institutionalised training plan for nurses, LHVs and midwives are needed to help them enhance and further develop new skills, knowledge and abilities and to make an effective contribution to the healthcare team. There is also a need to consider the composition of the health workforce in terms of both skill categories and training levels.

4.22 PROPOSED KEY STRATEGIES

SHORT TERM: ď&#x201A;ˇ

Develop mechanisms for gathering data on a regular basis for effective human resource planning for nurses 58



   

Analyse the current situation and develop a five year production plan in line with the healthcare needs of the Punjab province and the budget available with the health department so that production of nursing workforce can be matched with absorption of nurses in the public health care facilities A well developed institutionalised in service training programme for all levels of nursing cadres should be in place for a properly trained and competent nursing workforce New options for the education and in-service training of nurse professionals are to be evaluated in order to ensure that the workforce is aware of and prepared to meet the particular present and future needs of the Province of Punjab Consultative workshops with stakeholders to identify areas in which training could be offered through a yearly plan of refresher courses Introduction of low cost training models for nurses, LHVs and midwives. These include: o o o o o o o



      

Work with a mentor Observation or visits Buddy system Networking Conferences Seminars Meetings

For nurses working in rural settings, in service training programme to be delivered through: o Computer assisted learning programmes o Audio tapes and o video tape presentations Refresher courses to be initiated for those nurses, LHVs and midwives who have been away from work for more than two years. Initiation of one year specialised diploma courses for LHVs Institutionalised training programmes for building management capacities of senior nurse professionals. Training to build effective interpersonal communication skills to facilitate supervisors in providing effective feedback about performance of their staff and help them in achieving their personal goals. Leadership training to assist senior nurse professionals in building a climate of trust between themselves and their juniors. The underlying causes of poor performance to be evaluated and appropriate training conducted to address these. Monitoring and evaluation of the nursing institutes and impact assessment of the various programmes being offered by them,

MEDIUM TERM: 

Initiation of Degree programme for midwives and LHVs in collaboration with international academic institutes



Initiation of Masters Programme for nurses in collaboration with international academic institutes



Develop and establish a comprehensive HHR Department within the health system including a fully resourced and effective HRD section

LONG TERM: 

Initiation of Masters Programme for midwives and LHVs in collaboration with international academic institutes



Initiation of a PhD Programme for nurses in collaboration with international academic institutes

4.23 REGULATING THE NURSING PROFESSION

4.23.1 An overview The nursing organisations in Pakistan consist of a regulatory body, the Pakistan Nursing Council and the professional associations, the Pakistan Nursing Federation and the Midwifery Association of Pakistan. The PNC has a Nursing Examination Board in each Province. Under its approved Act (1973), the mandate of Pakistan Nursing Council is to protect the interest of the public and the profession. Hence, it is empowered to regulate and monitor the competence of all nursing professionals including nurses, LHVs and midwives who contribute to the delivery of health care services at primary, secondary, and tertiary level. The Offices of Senior Nurses include the Nursing Advisor Office at the federal level, Office of the Nursing Director of Armed Forces, and the Nursing Directorates at the Provincial level. The offices of senior nurses provide an official bridge and liaison between the government, education and health services. The NEBs work at arm’s length from the PNC, but in close collaboration with the Nursing Directorates of their provinces for monitoring the quality of nursing education. The PNF and MAP have the mandate of protecting the interest of nursing personnel and the profession, and thus work for the welfare of nurses, Lady Health Visitors and midwives .

4.24 PROPOSED KEY STRATEGIES

Short Term:  

Provide each cadre with scope and standards of practice Strengthen the role of the key professional organizations

Medium Term:  

Establish the nursing directorates at provincial level for enforcement of professional regulations, human resource planning and policy formulation Establish an independent LHVs association to safeguard the interests and profession of LHVs

Lady Health Workers There are no opportunities for the further development of LHWs. Being a federally administered national programme it would be difficult for Punjab to initiate a programme of continuing development for LHWs. It is recommended that discussion may be initiated in the first instance with the federal ministry, LHWs programme and other key stakeholders to explore options for increasing educational requirements for LHVs, upgrading their skills and developing programmes to support further development of those demonstrating potential to grow and progress. This may be linked with opportunities for entry into paramedic or LHV training schools for example.

RECRUITMENT AND RETENTION SECTION FIVE

5.1 GENERAL OVERVIEW OF RECRUITMENT AND RETENTION

Having the right people with the right skills in the right place is paramount for efficient, quality health care service delivery. Getting this right is dependent upon an effective, efficient and transparent recruitment process for all staff at all levels. Getting it wrong at this stage is expensive, inefficient and difficult to rectify later. Factors affecting the retention of staff are varied and complex. People leave an organisation for many different reasons which may be more personal in terms of salary and reward or more organisational related to working environment, values and ethics. There seems to exist a „push‟ and „pull‟ effect. The „push‟ usually relates to dissatisfaction in their current job and the „pull‟ to the attraction of a new job, new organisation. At times both may operate. An additional factor in staff retention is that of personal and domestic circumstances that are outside the control of the organisation. It has been well documented that first line managers and their behaviours have substantial influence over staff retention issues, performance and job satisfaction.1 The relationship with a line manager may most likely be the „push‟ factor in the decision of a staff member to leave their job and even the organisation. Additionally, another significant factor in terms of staff retention is that of growth and development opportunities. A lack of professional development opportunities and a career pathway are frequently factors influencing staff turnover. Health care services internationally are going through a period of profound change, particularly with the move from a focus on secondary and tertiary health care to community based primary and public health initiatives. Key professions most impacted by this change are those involved in planning, administration and provision of day to day care. Health professionals of all cadres need to be at the forefront of these changes. To achieve optimum health for its citizens, Pakistan needs to retain its health care workers as problems arise when there is an imbalance between the number of health professionals and the population of a country. This is true for all health care workers especially nurses and doctors who are considered to be on the front line in health care provision.

5.2 THE RECRUITMENT PROCESS IN PUNJAB

The authority for recruitment of district health staff has been devolved to the EDOH and both the EDOH and the DOH have authority for these functions according to BPS Grades i.e. the DOH has authority up to Grade 4 and the EDOH up to Grade 15 and Grade 16 for nurses.

C.I.P.D.2008

A District Selection Committee is convened under the authority of the EDOH for recruitment and selection. For Grades 16 to 18 the District Selection Committee under the authority of the EDOH makes the selection and then has to forward the recommendation to the Secretary Health for final approval. For Grades 19 and 20 the Chief Minister has the final authority. For Grade 18 and above appointment is by promotion only. In recent times most districts have been operating a â&#x20AC;&#x17E;walk-inâ&#x20AC;&#x; recruitment process, primarily for doctors, in an effort to expedite filling of vacant posts and additional posts created under the HSRP and MSDS. Vacancies are advertised in the local newspapers and applications invited from prospective candidates. Vacancies for recruitment are advertised on requisitions received from the administrative department. All applications are assessed for eligibility in accordance with service rules; executive posts require successful completion of the PSC examination.

Doctors When considering the recruitment of doctors there are many interrelated factors that affect the choice of career for doctors which also need consideration. Some of these may be influenced by such factors as salary levels, incentives, career progression, continuing medical education and professional development opportunities. Others are more difficult to change such as behaviour and attitude and socio-cultural influences.

5.3 RECRUITMENT AND RETENTION â&#x20AC;&#x201C; CURRENT SITUATION IN PUNJAB

5.3.1 Public Service Commission Prior to 1994 all recruitment for doctors was through the Public Service Commission The Public Service Commission is a statutory body under the government of Punjab originally established in 1937. The Commission is responsible for direct recruitment for various posts between Grades 16 to 22; recruitment for post 1-15 is outside the jurisdiction of the Commission. The primary function is to ensure all posts within these Grades are filled on merit in accordance with the recruitment policy of the government2. Applications are invited from prospective candidates through vacancy advertisements in the press. All applications are assessed for eligibility in accordance with service rules; executive posts require successful completion of the PSC examination.

5.3.2 Contracting System for Recruitment of Doctors

Recognising the shortfall of doctors and the high levels of absenteeism in rural health facilities across Punjab a contract system was introduced in 1994 in an effort to attract and retain more doctors for rural areas. Further, in 2004 in order to address some of the arising HR issues the government of Punjab developed a policy with defined rules and regulations for contracting of health staff.3 For male doctors the number of vacant posts has reduced significantly since the introduction of the contract system and the enhanced salary package. Currently an estimated 70 percent of BHUs and 80 percent of RHCs now have regular male doctors in post4 Recruitment for rural postings is the biggest challenge. 2 3

PSCP 2009 Contract Appointment Policy, December 2004, Government of Punjab. DGHS office, Aug. 2009

5.3.3 Recruitment and Retention of Female Doctors

As documented in Section 2 of this report there is no shortage of female medical students. This is not the situation in terms of practicing female doctors, most especially in rural areas and primary care facilities where there are currently over 4005 vacant posts for female doctors within the province. Various initiatives have been tried to encourage retention of female doctors, including financial incentives i.e. WMOs posted in „less attractive‟ THQ hospitals, an additional Rs.10, 000/- per month, „less attractive‟ DHQ hospitals, Rs. 6,000/- per month; Hard Area Allowance Rs.5, 000/- per month; this has had limited impact to date. Table 12 indicates the current vacancy position for doctors in primary and secondary health care facilities.

TABLE 12: CURRENT VACANCY POSITION IN DHQ, THQ, RHCS AND BHUS OF PUNJAB

NAME OF POSTS

SANCTIONED FILLED (UP TO JUNE POSTS 09)

VACANT POSITIONS

Anaesthetist

124

Gynaecologist

112

Medical Officers (DHQ)

644

386

233

Senior Medical Officers (THQ)

Medical Officers (THQ)

679

409

270

Senior Medical Officers (RHC)

291

217

Medical Officers (RHC)

291

229

Medical Officers/WMO (BHU)

2446

1856

590

Women Medical Officers (DHQ)

186

109

Women Medical Officers (THQ)

267

142

125

Women Medical Officers (RHC)

291

174

108

DGHS, July 2009

The cadre of various specialists, particularly for those specialities directly related to the achievement of the MDGs such as anaesthesiology, obstetrics, gynaecology and others such as radiology are singularly depleted. There are an estimated 70 percent of radiologistsâ&#x20AC;&#x; posts vacant in DHQ hospitals6. To further stimulate recruitment and retention of anaesthetists an enhanced remuneration package has been implemented from January 2007 in all health institutions with the exception of THQ and DHQ hospitals for which an enhanced package had already been approved.

TABLE 13: ALLOWANCES FOR ANAESTHETISTS

BPS Grade

Allowance per Month

Rs. 10.000/-

Rs. 15,000/-

Rs. 20,000/-

Rs. 25,000/-

Likewise, to support recruitment and retention of doctors under the health sector reform programme various incentive/enhanced remuneration packages have been implemented from January 2007 for SMOs, MOs and WMOs working in BHUs and RHCs as indicated in Table 14.

TABLE 14: HEALTH SECTOR REFORMS ALLOWANCES FOR DOCTORS

Health Sector Reforms Allowance

Rs.12,000/- per month

Practice Compensatory Allowance

Rs. 2,500/- per month

Additionally from June 2006 a Hard Area Allowance incentive of Rs. 5,000/- per month has been payable to Mos and WMOs posted in rural BHUs in an effort to maximise recruitment and retention in rural areas. Likewise since 2007 incentives have been provided for medical teaching staff in basic sciences as indicated in Table 15 to stimulate capacity in public sector medical education.

DGHS Aug. 2009

TABLE 15: TEACHING ALLOWANCES FOR DOCTORS

POST

PREVIOUS TEACHING ALLOWANCE

ENHANCED TEACHING ALLOWANCE

Demonstrator

Rs. 5,000/- per month

Assistant Professor

Rs. 7,000/- per month

Rs. 15,000/- per month

Associate Professor

Rs.10,000/- per month

Rs. 20,000/- per month

Professor

Rs. 15,000/- per month

Rs. 30,000/- per month

5.4 Analysis of Recruitment and Retention – Doctors Analysis under this study indicates that effective human resource planning, the foundation for any recruitment, is largely absent. This frequently results in ad hocism and a short term, „fire-fighting‟ approach thereby compounding many of the other human resource issues being faced by the Punjab health department. Recruitment practices generally across the public health system lack transparency and efficiency across all cadres.

5.4.1 Medical Students

Female medical students who are largely from urban areas prefer to work, following graduation, in a similar urban area to which they are accustomed. This is not exclusive to female doctors. The lack of community and primary health in the medical curricula does not prepare newly graduated doctors for a rural posting and many feel ill-prepared and lack confidence to practice in a remote rural area with very limited support mechanisms. Of the significant number of female medical students who enter the system each year it is estimated that as high as 70 percent will never practice but become housewives. This is related directly to status and socio-culture norms. A key factor is that marriage-ability is enhanced if a woman is a qualified doctor. There is often family pressure to train as a doctor for social status and equally family pressure not to practice but to get married. This would indicate that every year around 45-50 percent of all medical student/graduate intakes are „lost‟ to the system. This is a great financial loss also to the health department and medical colleges.

This situation would benefit from further more focused study in order to fully understand the influencing factors, the actual numbers involved and thereby be able to develop more appropriate mitigating mechanisms.

5.4.2 Contracting System of Recruitment for Doctors

This was in essence an innovative and relatively successful approach to fill vacant posts, particularly in rural areas in the short term. The number of doctors in rural postings increased significantly however, the implementation framework lacked adequate protocols and institutional HR management procedures and policies which have resulted in a number of HR issues. While initially providing comparatively better salaries in the form of a lump sum payment this incentive was soon offset by the lack of benefits or the long term security offered as per a regularised government posting. Similarly more focus was required on female doctors, a) to address the gender imbalance and b) to meet the need for female doctors for the provision of MNCH services and the achievement of the MDGs. Senior doctors who had been in service for a number of years initially resented contract doctors due to the enhanced salaries being offered. This created misgivings and frustration within the health system. Additionally, contracted doctors largely remained on BPS Grade 17 with no promotion structure available to them thus creating frustration as they remained in the same post and Grade for over ten years. In-service training opportunities for contracted doctors were also seemingly less available than for regularised doctors thus adding to the levels of frustration. One positive outcome of the contracting system, reportedly, was a considerable reduction in the number of random transfers. In order to address some of the issues arising from the contracting system from June 2009 the Punjab health department has reversed this practice, regularising general doctors and specialists up to Grade 18. Selection and examination for recruitment has now reverted back to the Public Service Commission. Regular recruitment of doctors through the Public Service Commission selection and examination process when vigorously applied provided a reasonable recruitment framework. The weakness was in the lack of rigorous application.

5.4.3 Recruitment and Retention of Female Doctors

Recruitment and retention of female doctors requires specific attention as a lack of focus on this issue has led to the gender imbalance within the health care delivery system, most especially in remote, rural areas witnessed today. The shortage of female doctors is not due to a lack of female medical students, rather there is an abundance of female applicants, students and graduates as indicated in Section 2. Retention in the health care system is the main issue. Likewise the recruitment of qualified female doctors back into the system after taking time out for family commitments or other reasons. The impact of this gender imbalance is of particular concern in relation to MNCH and the MDG targets both of which focus on women and children. Given the socio-cultural context of Punjab it is extremely important for women to have access to female doctors.

5.4.4 Medico Legal Work Affecting the Retention of Female Doctors

A further factor influencing the recruitment and retention of female doctors in rural areas is that of the requirement for women medical officers to be involved in medico legal work. This was a requirement by the government until recently, particularly for the performance of post-mortems on females. Additionally medico legal work requires considerable time to be spent in court appearances and on other legal matters for which the doctors, male and female, are not trained and for the most part do not feel comfortable undertaking. At times there are also issues from the community in respect of medico legal work which may threaten the security of staff to which females are more vulnerable. Under the health sector reform framework the system of medico legal work is being reviewed and revised with separate, dedicated units being established and staffed at district level to undertake all aspects of medico legal work. This will remove one of the major obstacles to greater female deployment in rural areas and will also greatly improve the medico legal system as a whole in rural areas.

5.5 GENERAL FACTORS INFLUENCING RETENTION OF DOCTORS

Several factors are affecting the retention of medical staff:

      

dissatisfaction with the working environment including the lack of resources and equipment lack of adequate training and experience in PHC lack of continuing professional development opportunities; CME lack of a career path; transparent promotion protocols irrational and frequent changes in posting increasing competition from attractive international opportunities private practice

These have all served to make the public service option considerably less attractive. This is resulting in high levels of absenteeism, for which reliable data is not available and a significant number of vacant posts, most especially for female doctors and specialists as indicated in Table 10. 5.5.1 Retention – Absenteeism

One of the presenting factors in relation to retention that would seem to indicate considerable levels of dissatisfaction within the system by doctors is that of the high level of absenteeism, predominantly in rural areas although not exclusively. This also raises concerns about the level of accountability and performance management within the health system. With reference to absenteeism there is no reliable data available and it is suggested that this would need to be the subject of further study and observation. Anecdotal evidence abounds and some estimates put the level as high as 60 percent in some rural areas. Some of the underlying causes put forward for such high levels of absenteeism among doctors in rural health facilities relating to the facilities themselves include:        

general under-resourcing lack of basic amenities such as potable water and electricity poor physical condition lack of equipment limited budget available for maintenance location of the facility – not well placed geographically under-utilisation by the local population security concerns 71

Some of the resource and physical infrastructure issues are now being addressed and are showing signs of improvement under the health sector reform programme. The issue of patient utilisation rates creates a cycle of discontent. For staff posted in such facilities the frustration and de-motivation levels rise frequently compromising quality of service and increasing absenteeism. For patients, absent doctors and poor quality service pushes then into seeking health care services elsewhere. Informal estimates of patient utilisation in some remote rural areas put utilisation as low as 25 percent and others quote 30 percent. This picture will become clearer as the DHIS becomes more widely used and the MSDS protocols become effective.

5.5.2 Retention in Rural Postings

The high level of absenteeism and the number of vacant posts reflects high levels of dissatisfaction with rural postings. The reasons for this are multiple and varied and as one study in remote rural areas of Australia showed work related issues were generally of more significance than that of lifestyle or personal issues.7 Similarly in Punjab the following were cited most frequently by key informants as detractors of rural postings: DETRACTORS OF RURAL POSTINGS



lack of resources, equipment, medicines and basic amenities within the health facility



professional isolation and lack of supportive networks



lack of access to professional development opportunities



lack of recognition of rural primary care service for post graduation



lack of organisational support



security issues; particularly pertinent for female doctors although not exclusively



lack of respect from the community



political interference



frequent changes in postings



social isolation

Australian Journal of Rural Health; 1995

Additional factors include issues around accommodation, particularly accommodation for married staff with families; although not a real problem if the doctor is from that locality and is within easy daily commuting distance; availability of educational facilities for doctors with young children and transport, especially for females.

5.6 INCENTIVES

Recent initiatives to support doctors in rural postings, such as rent-free accommodation for postings in BHUs and RHCs or 30 percent of basic pay in rural areas and 45 percent of basic pay in urban areas as housing allowance are going some way towards improving retention; the longer term impact of these initiatives has yet to be assessed. Similarly the provision of daily travel allowances with rates according to BPS Grades is giving some incentive to improve retention in rural areas but more needs to be done.

5.7 POSTING NEWLY QUALIFIED DOCTORS TO RURAL AREAS

An additional factor for consideration is that of posting newly qualified doctors to remote, rural facilities. With little or no exposure to primary health care due to inadequacies in the medical training curricula and practical learning opportunities the doctors not only feel isolated professionally and socially but also lack experience and confidence to work in such a situation. This not only affects the quality of care but also the job satisfaction of the doctor who feels s/he was trained to work in a well equipped teaching hospital in a major urban area.

5.8 REMUNERATION PACKAGES AFFECTING RETENTION

Doctor‟s salaries are still very low compared to bureaucrats, corporate sector and other professions. The average salary for a newly qualified doctor entering the service on BPS Grade 17 would be in the range of 18,000 – 22,000 RPs/- per month with benefits while that of a graduate of a prestigious business school for example would be in the range of 60,000 to 65,000 RPs/- per month. As a consequence many doctors stop practicing to take up other professions simply in order to make a decent living wage. Others revert to private practice and many undertake both public and private practice. A further consideration in this respect is that many medical students complete their studies in debt or at least constrained financial circumstances having had to finance their living during their studies for at least five years. For new graduates this means they need to earn more to pay back or at least cover some of the costs of their studies; not all student doctors come from wealthy families. This often pushes newly qualified doctors into dual practice – public and private thus setting a trend that is then difficult to break. 73

A key issue for many doctors is that of making a living income for themselves and their dependents. Pakistan has seen considerable inflation over the past few years and the cost of living has increased significantly. Additionally, more people recognising the importance of a good quality education for their children are pushed into additional work to supplement the family income to cover not only basic living costs but provision for their children‟s education and increasingly health care.

5.9 RETENTION IN PUBLIC SERVICE OR SETTING UP IN PRIVATE PRACTICE

The issue of public sector doctors undertaking private practice is an on-going debate within the health sector and solutions are not easy to determine. The fact is that for an estimated 65 to 75 percent, no reliable data is available of public sector doctors undertake private practice at some point in their career. The level of income generated from their private practice varies widely from Rupees 20, 000/- per month from a modest evening practice in their home to over a million rupees per month for those specialists with a well established clinic. This is highly significant income especially when one considers the average salary of a senior general cadre doctor would be in the range of 50 to 70 thousand Rupees per month including benefits. The legality of private practice for public sector doctors is also unclear with various references to private practice being allowed within certain parameters i.e. practice from their own home after regular hours; private patient consultations in the teaching hospital provided that if the patient requires hospitalisation the patient is admitted to that same teaching hospital and a proportion of the income from the private consultations is given to the hospital. There have been some attempts to „regularise‟ private practice for public sector doctors to more clearly define the parameters and ensure adherence to those parameters. These have not been rigorously applied for the most part. Estimates vary, and data does not exist to support this however, some estimates indicate that 90 percent of private practice is provided by doctors from the public sector. There is a non-practicing allowance intended to be an incentive for public sector doctors not to undertake private practice. The amount however, even following increases in 2007, is still negligible as indicated in Table 16. Clearly this is having little impact upon the magnitude of the situation.

TABLE 16: NON-PRACTICING ALLOWANCES

BPS GRADE

PREVIOUS ALLOWANCE

REVISED ALLOWANCE

BPS 17-18

Rs. 500/- per month

Rs. 4,000/- per month

BPS 19-20

Rs. 700/- per month

Rs. 6,000/- per month

It is suggested that much more extensive assessment of the full extent of private practice by public sector staff would need to be undertaken in order to recommend protocols to influence this situation. What is clear is that a huge number of person hours are being lost to the health department through dual practice. It is understood that some aspects of this may be being addressed in work on the establishment of a Health Commission under the PDSSP.

5.10 SUPPORTING RETENTION WITH SUCCESSION PLANNING

A further and increasing concern for the health department, largely as a result of the contracting initiative is that of succession. Under the contract system as doctors largely remained on BPS Grade 17 with very limited promotional opportunities it soon became evident that as staff are lost to retirement, illness, death and other reasons there is a lack of replacements available moving up through the system and BPS Grade. There was an almost total lack of trained medical staff being promoted up through the health system. This also impacts upon retention. If doctors do not see a career path ahead with promotion opportunities they are more likely to leave the system. Similarly this is affecting the faculty staff of medical colleges. As many senior medical/faculty staff retire within the next few years8 there is a lack of available qualified and experienced staff to replace them. This will also further impact on the quality of medical education. Since 2007 incentives have been provided for medical teaching staff in basic sciences as were indicated in Table 13.

5.11 RETENTION â&#x20AC;&#x201C; MIGRATION

For the Punjab health department already facing a shortfall of qualified doctors and specialists, particularly female doctors, with a continuing shortfall anticipated depending upon such issues as productivity levels, population growth and demographic changes the loss of an estimated 1,500 to 2,000 emigrants per year and rising is compounding the problem. When considering the retention of health care workers in Punjab and many other countries the issue of migration inevitably arises. The migration of health care workers is a challenge in the global context and is affecting the health care systems in many countries. Frequently depleting developing countries health human resource levels as more and more health care professionals seek employment overseas9. Developed countries themselves facing 8 9

KEMU July 2009 Vujicic et al 2004, WHO

increasing shortages of health care professionals look to developing countries for recruitment10. The international migration of doctors from South Asia is not new; beginning in the 1950s and 1960s and growing in the 1970s as a post-colonial phenomenon common to India, Sri Lanka and Pakistan, later extending to Bangladesh and Nepal11. In Pakistan, the Fellowship of the Pakistan College of Physicians and Surgeons has been recognized as equal to the Royal Colleges‟ Membership and the American Boards‟ Diploma in many countries. This facilitates migration of Pakistani doctors. There is significant loss to the Middle East, UK and US in particular. While many Pakistani doctors leave the country for the United States and United Kingdom, mainly to acquire higher qualifications, many of them never return. According to the Immigration Bureau of Pakistan, 6424 doctors have left the country during the last five years. This official figure is believed to be a gross underestimation. Similarly it has been observed that internal migration of health care professionals closely follows that of other workers migration patterns in the internal movement of the workforce from rural to urban areas12. The population spread in Punjab is currently estimated at 35 percent urban and 65 percent rural13. This clearly also impacts upon the supply and balance of qualified health care providers and is evidenced across Pakistan where health facilities in major cities and urban areas are at times over-staffed while in comparison in rural health facilities posts remain unfilled. In a WHO study looking at six African countries14 the following were found to be the key factors influencing the decision to migrate or emigrate. These are not listed in order of priority: FACTORS INFLUENCING MIGRATION           

Salary levels Desire to upgrade qualifications Desire to gain more experience Improved living and working conditions Promotion opportunities Recognition To save money Workload Security – violence and crime in country of origin Economic decline in the country of origin Declining health care systems in country of origin

Any one of these could be equally applicable in Punjab.

Vujicic et al 2004, WHO Adkoli 2006 12 WHO 2004 13 GoP Statistics Bureau 14 WHO; 2003 11

5.12 RECRUITMENT AND RETENTION – KEY CHALLENGES



Lack of transparent, efficient mechanisms and protocols



Challenging working environments



Lack of effective human resource planning



Lack of recognition and reward



Limited opportunities for professional growth and development



Ineffective people management



Poor performance management



Migration for better prospects

5.13 PROPOSED KEY STRATEGIES – RECRUITMENT OF DOCTORS

Key Challenge: Shortfall in number of doctors available in the market The key objective is to increase the output of doctors to meet the shortfall Short Term:   

conduct an audit of exact number of doctors available forecast requirements for the next 5-10 years review productivity levels of medical colleges

Medium Term:   

adjust the number of medical college seats to meet the productivity requirements allocate funds in the annual budget if additional seats required explore options for checking migration; international protocols; Malawi and Tanzania

Long Term:   

review the staffing need for doctors review the productivity requirements for doctors adjust the productivity levels according to need

Key Challenge: Non-practice of female medical graduates The key objective is to increase the number of female medical graduates taking up posts within the Punjab health department Short Term: 

pay special attention to the selection and enrolment of female medical students; enhance screening protocols 77



career counselling for all medical students

Medium Term:  

establishment of an enforceable bond system for two years commitment to practice improved working environment to support female doctors including: o enhanced safety/security o improved housing; provision of married accommodation or appropriate allowances for living with their families o increased budget for transport allowance for areas which are difficult to reach o day care facilities or support for child care o flexible working hours

Long Term: 

more favourable working conditions for female doctors institutionalised

Key Challenge: Varied and selective application of transparent recruitment protocols The key objective is to institutionalise effective recruitment protocols at all levels Short Term:   

development and implementation of effective and transparent recruitment processes supported by policy and procedure; strengthen the PSC protocols and application regularisation of all doctors posts develop HR plans for need based recruitment

Medium Term:   

institutionalise effective recruitment practice based on actual need development of HR plans supported by recruitment planners effective HR planning according to actual need

Key Challenge: Low salary levels The key objective is to provide competitive salary levels Short Term:   

review market rates assess budget availability and costing implications increase current salary packages

Medium Term:   

adjust salary levels within budget frameworks increase incentive packages provide non-monetary options for incentives such as: o staff of the month awards o training credits o letters/certificates of acknowledgement

Long Term:   

further adjustment of salary levels set annual incremental increases in salaries for next five years initiate further incentive packages; non-monetary and monetary

Key Challenge: Shortage of specialists in secondary care facilities The key objective is to increase the number of specialists in secondary care facilities to meet MSDS. Short Term:  

provide short course essential training for doctors in anaesthesiology as a stop-gap measure essential rotational placements for at least three months from tertiary and teaching hospitals for the required specialists

Medium Term:    

recognise secondary facilities as affiliated placements for post graduates mandatory short term practice in secondary facilities for all relevant specialists increase incentive packages for specialists in rural postings provide accommodation and transport allowances

Long Term:    

increase specialists training output through more attractive packages and training opportunities review need based on HR plans increase incentive packages reduce migration through international code of practice and improved working environment including: o attractive salary packages o suitable accommodation o improved physical environment o provision of adequate resources o transport allowances o

5.14 SUMMARY OF KEY POINTS FOR EFFECTIVE RECRUITMENT PRACTICE



Recruitment must be the foundation for all other HR activity



Must be well planned and according to need



Line managers in addition to the HR team to be involved in the recruitment process



Selection must be based on relevant experience, qualifications, 79

performance history, skills and ability and potential to further develop. 

Experience, skills and qualifications must be relevant to the requirements for the job in terms of competencies and person specifications.



Effective recruitment must be followed by meaningful induction

5.15 STRATEGIES TO STIMULATE RECRUITMENT OF LOCAL PEOPLE



Local recruitment campaigns and „mela‟ that are attractive, interactive and informative with follow up options; this could be in the form of a mobile unit or convened in the local school, hospital or government offices



Career counselling for potential recruits



Career counselling for parents



Hospital/ health facility „open days‟



Training institutions „open days‟



Establishment of local recruitment centres e.g. one in each district with the option for more at Tehsil level if staffing and resources allow

It is envisaged that such strategies could be developed and implemented in the short to midterm i.e. one to two years and would be integral to the development of the human resource departments. The strategies could be further strengthened and tailored to local needs as experience is gained. Annex 10 indicates the main stages in good practice recruitment

5.16 DEVELOP SUPPORT NETWORKS

Support networks are extremely important for staff based in rural areas both in terms of professional and social support mechanisms. Building onto the cluster approach that has been developed to link FLCFs with the THQ and DHQ hospitals is recommended as a sound mechanism to enable staff to develop their social and professional networks. This will offset social and professional isolation problems as have been highlighted as detractors for rural postings. Annex 10 gives an outline of the main stages in good practice recruitment.

5.17 PROFESSIONAL DEVELOPMENT OPPORTUNITIES

For doctors posted in rural areas it can be an excellent opportunity to pursue further studies and have their rural service counted as credits for post graduate qualifications. The provision of e-learning would significantly enhance such opportunities in the medium to long term while in the short term provision of journals and modern literature is recommended and

linked to the cluster approach through the development of modest lending libraries or eaccess wherever possible.

5.18 PROPOSED KEY STRATEGIES – RETENTION OF DOCTORS

Key Challenge: Vacant posts in rural areas The key objective is to fill all vacant posts in rural areas. Short Term:             

recruit local people; post staff in posts close to own residence continue to upgrade rural health facilities upgrade accommodation including family accommodation improve incentive packages particularly for hard to fill posts build community confidence and involvement through local health management committees to increase staff security further strengthen „cluster‟ approach linking FLCFs with the DHQH to form a „network‟ for professional as well as social support mechanisms for staff encourage local social and professional events between clusters support monthly/quarterly professional events e.g. seminars, debates, quizzes stop irrational transfers and postings mandatory placement of post graduate students in THQ/DHQ hospitals offer „back to work‟ packages for qualified doctors who left the profession; target women; provide induction programmes for re-integration provide overtime and extra shift/on-call payments to harness „dual practise hours‟ mandatory registration and regulation of private practice

Medium Term:           

strengthen educational opportunities in rural areas to build a pool of talent for recruitment at local level strengthen rural training institutions and faculties for training in local areas; this has been particularly successful in Australia and Canada revise medical curricula to include more on PHC include primary and secondary health care facilities in the affiliated facilities for teaching and training promote and support GP vocational training provide incentive packages in line with market rates develop public private partnerships to support local health facilities provide basic recreational facilities for clusters e.g. table tennis, volley ball, basic gym, library, e-learning opportunities provide access to professional development opportunities through e-learning; training events in DHDCs; provision of journals and key literature; mandatory rotation in FLCFs for all doctors during training adopt rational recruitment and promotion protocols 81

  

provide incentives to medical schools promoting rural and GP practice; refer to Australian and Canadian models provide financial support for students from rural areas provide double shift payments to harness dual practice hours

Long Term: 

develop new modules in the medical curricula for those students from local areas and interested in working in rural areas to undertake as special options with credits; this has proved successful in Australia and Canada

Proposed Key Strategies – Management of Gender

Special attention needs to be given to the gender imbalances within the health sector. The gender imbalance within the health department is largely reflective of the gender imbalance within the broader workforce across Punjab which in turn is reflective of the gender issues within society as a whole. To address gender issues at the broader level will require behavioural change over a sustained period of time however, there are an increasing number of women moving into the workforce and the health sector and positive action is needed to retain them and support their professional growth. Key Challenge: Gender imbalances The key objective is to reduce the gender imbalance Short Term:     

develop more rigorous selection procedures of female medical students; assessment of intention to practice provide part-time and flexi-time working options for women and working parents remove medico legal work for WMOs in rural areas promote „back to work‟ initiatives for women who left the profession to have a family remove of all age restrictions for recruitment and training of female doctors

Medium Term:  

establishment of an enforceable bond system for two years commitment to practice effective gender conscious HR planning based on actual need

5.19 SELECTION OF FEMALE MEDICAL STUDENTS

Recognising that there is no shortage of medical student applications and that the number of female applicants and students is higher than that of males currently the challenge is not in sourcing students. The challenge lies in recruiting students who are willing to continue in the medical profession following completion of medical education. This requires a combination of more rigorous recruitment and selection procedures and essential student and parent career counselling and advice. The intention is to weed out potential students, especially females who have no long term commitment to medical practice. Although this may initially result in lower numbers of female students ultimately it would actually increase the number of practicing post-graduate students thereby increasing the total outflow of doctors each year. Special attention will need to be given to the selection of female medical students in order to more accurately determine their intention to practice following successful completion of medical education. Additionally, in the medium term there must be an enforceable commitment to practice agreement, a bond, as a condition for entering medical college.

5.20 SUMMARY OF KEY STRATEGIES FOR ADDRESSING THE GENDER IMBALANCE

Summary of Key Strategies for addressing the Gender Imbalance 

Career counselling for potential students and parents



More rigorous screening and selection of female potential students for medical education in terms of aptitude and intention to practice



Requirement to practice for at least two years as part of the selection criteria enforceable through a bond system with financial penalties for non-compliance in the form of full payment for all training costs including the imposition of a financial penalty



Flexible working opportunities i.e. part-time; flexi time



Promote a return to work policy for women who left the profession to have a family



Provide a supportive and conducive working environment



Cluster or team approach in rural areas for social and professional support networks



Removal of the need for female doctors to be involved in medico legal work



Transport arrangements i.e. pick and drop



Where feasible post at least two females together



Provision of secure accommodation



Whenever possible post with or close to spouse‟s posting



Provide support for child care – e.g. crèche facilities in hospitals; ayah allowance in FLCFs; pick and drop for local schools

5.21 CAREER COUNSELLING

Career counselling is a relatively low cost, effective mechanism for supporting and promoting the recruitment of young people into the health care service. Effective career counselling for potential students and their parents will potentially reduce drop-out during training and increase the likelihood to practice following completion of training. This is particularly pertinent for female medical students.

5.21.1 Proposed Key Strategies – Career Counselling

Key Challenge: Recruitment and Retention of female medical students Short Term:

  

develop a career counselling service with trained counsellors establish career counselling sessions as part of the protocol for medical student selection; include parents promote recruitment through open days in local health facilities with staff on hand to give information and advice to interested young people

Medium Term:  

establish mobile career counselling units in each district with regular visits and events to cover each tehsil as a minimum hold regular career planning sessions in schools and colleges

Long Term: 

provision of career counselling to all potential health professionals

5.22 TAKING LESSONS FROM INTERNATIONAL MODELS

There are many countries facing very similar HR challenges to those in Punjab and Section 9 highlights five such countries. Of particular relevance for the recruitment and retention of doctors are issues relating to medical education for rural doctors as seen in Canada and Australia. Similarly the importance of exploring options for incentives to medical schools promoting rural and GP practice and financial support for students from rural backgrounds needs

further attention. A further longer term initiative for consideration is the development of a national institution to focus on development of education for rural practice. Funding Models for Promoting Rural and GP Practice - Australia1516 

Enhanced government funding to provide longer and better supported placements in general practice and rural practice for all medical students



Increased funding, resources and support provided to develop teaching general practice. This will attract more GP role models and recruit more practices to train students



Additional resources provided to encourage GPs to host junior doctors through a postgraduate general practice placement programmes



A general practice attachment should be mandatory and available for all junior doctors in either PGY1 or PGY2



Government funding of new community clinical schools in each medical school



Funding provided for rural clinical schools; would provide a substantial increase in the quality and quantity of general practice exposure provided to medical students and junior doctors and will have an impact on their ability to make informed choices about their future careers.

15 16

Australian Government, 2007 Australian Health Care Research Institute 2007

Nurses, Midwives and Lady Health Visitors 5.23 OVERVIEW OF RECRUITMENT AND RETENTION – In 1947 Punjab had a population of about 22 million; in 2009, the population of the province has risen above 90 million. There are only 8921 nurses against 56,711 doctors in the country which is contrary to international standards. This depicts a wide gap between the demand and availability of nurses. Though Punjab has over half the nursing institutes of the country and is producing nurses in a variety of health care settings, many nurses are however, unfortunately leaving the country. The health department is unable to retain enough nurses to meet the demands of the health care system. According to available statistics, 15 percent of nurses from developing countries like India, Philippines and Pakistan are moving to developed countries every year. Graduate nurses have a greater potential for moving abroad compared to other professions. It was stated that “every year western countries hire 33 percent of nurses for their health care units only from The Aga Khan University Nursing School, Karachi Pakistan.17”

5.24 RECRUITMENT PROCESS

5.24.1 Nurses The recruitment process for nurses is by initial appointment in BPS Scale 16. The posts are advertised and the appointments made through the Director General of Nursing. Currently all regular nursing posts in the Punjab health department are filled however, there are vacancies under contractual appointments. For Head Nurses and Asst. Nursing Instructors in BPS Scale 17, 1/4th are recruited through initial appointment, whereas 3/4th of appointments are made through promotion of nurses in BPS Scale 16 on the basis of seniority cum fitness. There is no institutionalised policy as some nurses are reported to have been working for over two decades in BPS Scale 16, whereas recruitment rules do cater to the number of years of experience for appointment into the next level. For all the remaining appointments in BPS Scale 17, 1/3rd of the recruitment is through initial appointment, whereas 2/3rd of the appointments are through promotion only, taking into account the seniority, fitness and higher qualification.

Khowaja (2007)

For BPS Scale 18 and above, all appointments are made on the basis of seniority and fitness. Details Attached as Annex 12.

5.24.2 Lady Health Visitors The appointment of LHVs is under the jurisdiction of the EDO Health. Director Health Services at the DGH office also looks into LHV appointments. All recruitment is currently contractual in BPS Scale 9. Due to the limited number of sanctioned posts and the high annual output of LHVs, there are several applicants for any post advertised.

5.24.3 Midwives Midwives are recruited directly at the district level by the EDOH and at the Tehsil level by the MS of the hospitals. The DG Nursing office has no formal notification of these appointments. All are contractual appointments.

5.25 RECRUITMENT AND RETENTION â&#x20AC;&#x201C; CURRENT SITUATION IN PUNJAB

5.25.1 Nurses Presently in Punjab nurses are working on both regular and contractual basis. Recrutiment under contractual appointments is only for BPS Scale 16 and 17. There is no clause for conversion of contractual appointments into regular appointments even after satisfactory performance for several years. Also there is no clause for study leave in these contracts, making it difficult for these nurses to enhance their qualifications. For contracted nurses the maternity leave privillage is provided only once in five years. A recent notification, August 2009, has now been received from the health department for conversion of contractual appointments into regular ones. This is expected to have an impact on retention and filling of vacant posts. Under regular appointments 6239 nurses are working in BPS Scale 16 as Staff Nurses (often referred to as Charge Nurses). In BPS Scale 17, a total of 800 nurses are appointed on different posts as highlighted in Table 2; 79 nurses are working in BPS Scale 18, 13 in BPS Scale 19 and only one in BPS Scale 20. This makes a total of 7132 nurses working against 7545 sactioned posts for regular appointments of nurses in Punjab. There are a total of 3751 sanctioned posts available for contractual appointment of nurses in BPS Scale 16 and 17. Only 1768 nurses are utilising these vacancies in BPS 16 and 21 in BPS 17. Only 36 male nurses are working as Charge Nurses in Punjab. Details attached in Annex 5.

5.25.2 Lady Health Visitors Interestingly LHVs sign a surety bond of three years at the time of enrolment into the course, but it is of little value as since 1992, the recruitment of LHVs is on contractual appointments. Hence there is no surety of job placement for the qualifying LHVs. The appointment of LHVs is under the jurisdiction of the EDO Health. The Director Health Services at the DGH office also looks into LHV appointments. One LHV is allocated per Union Council. For primary health care facilities, the following criteria are being observed:     

BHU Level RHC Level MCH Centre THQ Level DHQ Level

1 LHV 3 LHVs 1 LHV 1 LHV Nil

Another rough estimate is made on the basis of population, i.e. 1 LHV per 10,000 head of population. In Union Councils however, where the population is more than 10,000, still only one LHV is posted. The LHV profession suffers both from vacant posts in some areas and unemployment due to the lack of sanctioned posts in others.

5.25.3 Midwives At the time of enrolment in midwifery schools, a four year service bond is signed; the government is under obligation to provide placement to the qualifying midwives within one year otherwise the bond lapses.

5.26 ANALYSIS PROFESSIONALS

RECRUITMENT

AND

RETENTION

–

NURSE

5.26.1 Retention

Retention of capable nurses, midwives and LHVs is more challenging than any other cadre of health human resource in the Punjab health department. This is due to the lack of incentives and no clear cut career path. The salary packages are minimal as compared to what nursing professionals are offered for overseas employment. Moreover the upgradation in qalification to a post RN BScN and BScN and post basic diplomas other than that of Management and Administration are not recognised under the existing service rules for any incentive or promotion. 88

5.26.2 Shortage of Qualified Nurse Professionals

The majority of registered nurses in the country are diploma holders. Despite several Colleges of Nursing now enrolling students in the Bachelors Degree Programme, the service rules do not acknowledge this higher qualification. This leads to a considerable number of nurses seeking employment overseas leaving a shortfall in Pakistan.

5.27 SHORTAGE OF SANCTIONED POSITIONS IN VARIOUS CATEGORIES

Although there is an extreme shortage of available nurses, LHVs and midwives to meet the health needs of the population of Punjab, the shortage of sanctioned posts in various categories deters the optimal utilisation of the available nursing workforce in the province. There is an estimated 2500 qualified LHVs to date; the yearly output is an average of 1000 LHVs. With the lack of sanctioned posts, many of these LHVs remain unemployed despite the shortfall in the health sector. Despite having signed a service bond of four years at the time of enrolment, there is no absorption plan for the midwives and LHVs.

5.28 POOR IMAGE

The poor image of nursing in Pakistan is a setback for nursing to advance professionally. In a study conducted by AKUSON in 2007, it is highlighted that: “There is no denying in the fact that nurses play a major role in delivering health care services. Their round-the-clock presence, observation skills and vigilance allows doctors to make better diagnoses and propose better treatments. They provide care and assist in cure, participate in rehabilitation of the patients, and provide support to the healthcare providers‟. No other health care professional has such a broad and far-reaching role. Yet, the irony is that in our part of the world, they are still struggling against the norms which have denied them their due place among the professionals. This sad state of affair has compelled a number of qualified nurses to migrate abroad for better prospects – creating a vacuum in Pakistan”.

5.29 UNATTRACTIVE SALARY PACKAGES AND POOR WORK ENVIRONMENT

The major reason for increased turnover, decreased retention and nurse migration is the un attractive work environment that is generally prevailing in the province as compared to what the competent nurse professionals are able to enjoy overseas. The major factors are:  

lack of proper and secure residential accommodation lack of availability of transport facilities to reach out to certain remote areas for work 89

   

unsatisfactory educational facilities for their children in rural areas lack of support like day care facilities poorly equipped healthcare facilities disabling quality healthcare service delivery lack of professional advancement opportunities.

5.30 Migration

Pakistan as many other developing countries have trained nurses to meet their health care needs and achieve the Millennium Development Goals. Unfortunately in the absence of human resource planning, these nurses are leaving the country for better opportunities. The United Kingdom, Canada, and the United States of America are the most popular countries where Pakistani nurses would like to work and migrate. The reasons for Pakistani nurses moving abroad are linked to the fulfillment of basic human needs, self esteem, safety and security needs. A study was conducted at the Aga Khan University School of Nursing titled “Nurses Moving Abroad: The Reasons, Recommendations and Implications for Practicing the Nursing Profession in Pakistan”.

TABLE 17: RECOMMENDATIONS BY THE RESPONDENTS FOR THEM TO STAY AND WORK AS NURSES IN PAKISTAN Recommendations

Rank

Frequency (f)

Percentage (%)

High salary package

240

78.17

Positive work environment

213

69.38

Job security

209

68.07

Good healthcare facilities

209

68.07

Enhance nursing image

209

68.07

Higher educational facilities

200

65.14

Residential facilities

181

58.95

Transportation facilities

176

57.32

Political and economic stability

Equal rights to all civilians

I do not like to leave Pakistan

10.5

Medical facilities for nurses‟

10.5

160 156 7 7

52.11 50.81 2.28 2.28 90

n = 307 Based on multiple responses

TABLE 18: REASONS WHY A COUNTRY WAS SELECTED BY THE RESPONDENTS TO WORK IN AS A NURSE

Reasons

Rank

Frequency (f)

Percentage (%)

High salary package

220

71.66

Good nursing image

198

64.49

Good health care facilities

197

64.16

Higher educational facilities

182

59.28

Job security

172

56.02

Positive work environment

169

55.04

Equal rights to all civilians

162

52.76

Political and economic stability

Relative live in this country

Due to Holy and religious places/

117

38.11

110 10

35.83

3.25

n = 307 Based on multiple responses

5.31 NURSES PERSPECTIVE

RETENTION

AND

MIGRATION

–

INTERNATIONAL

5.31.1 Nurse Migration Nurse migration can be described as “the movement of nurses from one place/country to other place/country for nursing practice18”. Therefore shortages of nurses are reported in both developed and developing countries. It is found that developed countries overcome their shortage through international migration It was reported that the “United Kingdom and the United States are among several developed countries currently experiencing shortage of nurses … these countries encourage

Buchan, Jobanputra, Gough, and Hutt, 2005

nurse migration for fulfillment of their needs19”. As a result, developing countries are at an increased chance of experiencing shortage of nurses. In a study on “International Migration of Indian Nurses20”, it was indicated that 63 percent of the respondents expressed their intention to migrate. It also identified that economic factors, dissatisfaction with working conditions and unhappiness with prevalent social attitudes towards nurses are the main factors for the international migration of Indian nurses. It was also observed that the nurses working in government sectors were less keen to migrate as compared to private sectors nurses, as they had better opportunities in terms of pay scales, relaxed working environment and job security. It was reported from a survey21 mailed to 200 Philippine hospitals chief of nurses that RN staffing in government hospitals is more favourable than in private hospitals. They found that higher salaries, better benefits, and good career opportunities were the most effective incentives for both recruitment and retention. In a WHO report from the secretariat about the recruitment of health workers from the developing world, it was said that in Africa, difficult working conditions, characterised by heavy workloads, lack of equipment, poor salaries, and diminished opportunities for advancement resulted in increased migration out of Africa. It was found that the current level of unemployment of nurses in China has created interest in migration among nurses22. Nurses were concerned about low wages, working conditions, and lack of job security.

5.31.2 Recruitment and Retention

In Canada recruitment and retention of nurses has improved by implementing the strategies enlisted below:    

Increase in funding to strengthen recruitment, retention and education of nurses Allocating budget for 30 new seats that were funded to prepare nurse practitioners at the University of British Columbia and at the University of Victoria Funding made available for additional nurse practitioner positions within communities. Most provinces and territories in Canada have moved the academic entry requirement for registered nurses to the baccalaureate level, while increasing the length of programmes for Licensed Practice Nurses to meet the increasing complexity of patient-care needs.

There is a tendency for developed countries faced with decreasing numbers of nationally trained nurse personnel to recruit already-trained individuals from other nations by enticing 19

Ross, Polsky, and Sochakski (2005) Thomas, (2006) 21 Perrin, Hagopian, et al. (2007) 22 Fang (2007) 20

them with incentives. Zimbabwe has been particularly affected by this problem. In 2001, out of approximately 730 nursing graduates, more than one third (237) of them relocated to the United Kingdom Countries that have the capacity to educate more people than necessary in order to meet their domestic demand have tried to counterbalance this problem by increasing their training quota. It was identified that “the Philippines has for many years trained more nurses than are required to replenish the domestic stock, in an effort to encourage migration and increase the level of remittance flowing back into the country23”.

5.32 PROPOSED KEY STRATEGIES

5.32.1 for Nurses The government of Punjab needs to adopt a policy of retaining nurses through a provision for improved working conditions, better remuneration, quality education and training – above all recognition and respect to nurses. In Pakistan there is a need for development in the social and cultural arenas for removing stigmas attached to the field of nursing which would help retention of nurses. Losing professional nurses to migration in other countries in an already depleted health care workforce further aggravates the poor health situation in the country. The government must recognise migration issues as real and must implement legislative actions to help correct poor salaries and working conditions, notwithstanding the poor image of nursing in the country. There is a need to establish effective strategies that are designed to ensure adequate staffing in order to successfully undertake implementation of national health care plans. Short term:   

   

all attempts should be made to fill vacant posts. there is a need to regularise all contractual appointments among different nurse cadres a five year absorption plan for the graduate nurses must be in place for optimal utilisation of nurse output every year; create new essential posts for nurses at all levels deployment of nurses to be based on the workload of BHU, RHC, DHQ, THQ conducting a study to identify factors leading to filled posts in certain health centres and persistently vacant posts in others. job descriptions to be provided to all staff and career counselling sessions held periodically. conduct a survey to map out the available nursing workforce for effective human resource planning

Vujicic et al. (2004)

 

develop a deployment plan in order to have centralised deployment for the health human resource based on assessment and analysis of current status concrete steps should be taken towards improvement of working conditions. These include: o enhance safety/security for all nurses, midwives and LHVs o improved housing for nurses, midwives and LHVs. Providing married accommodation or appropriate allowances for nurses living with their families o increase budget for transport allowance for areas which are difficult to reach o day care facilities for the young children of nurses, midwives and LHVs o initiation of a Masters Degree Programme for nursing

Medium Term   

a career counselling section to be developed to provide a comprehensive plan to promote specialities and cadres which are relatively more deficient ensure effective implementation and monitoring of the human resource plan by making the EDOHs accountable enhancement of students seats according to provincial needs

Long Term 

initiation of a Doctorate Programme in Nursing

5.32.2 For Lady Health Visitors

Short Term      



all posts for LHVs to be regularised BPS scale of LHV be revised and brought up to BPS 14 establishment of LHV association as a forum for advocacy and safeguarding interest creation of sanctioned posts to absorb the yearly output of LHVs from schools of public health deployment of LHV to be based on the workload of health facilities concrete steps should be taken towards improvement of working conditions; these include: o enhance safety/security for all LHVs o improved housing for LHVs. Providing married accommodation or appropriate allowances for comfortably living with their families o increase budget for transport allowance for areas which are difficult to reach o day care facilities for the young children of LHVs initiation of one year specialised Diploma courses for LHVs in subjects including but not restricted to Paediatrics, Family Planning, Vaccination, Hygiene, Nutrition, Viral Diseases, Midwifery, Public Health, Management and Administration.

Medium Term 94



initiation of post LHV Bachelor Degree Programme in collaboration with international universities, till own faculty is prepared to take over academic appointments.

Long Term 

initiation of post LHV Masters Degree Programme in collaboration with international universities

5.32.3 For Midwives

Short term     



increase the number of sanctioned posts for midwives in order to absorb the number of midwives coming out of midwifery schools every year strengthen the Directorate of Nursing for properly regulating the recruitment of midwives job descriptions to be handed over to the midwives at induction and their roles and responsibilities clearly explained initiate one year advance Midwifery Diploma for nurse midwives wanting to advance their careers in midwifery update curricula to ensure that nurse midwife is educated to work as a role model in the community for midwifery practice to provide safe, competent, and holistic nursing care in primary and secondary level in the community. institutionalised refresher courses for existing midwifery tutors to refresh their knowledge and enhance their skills

Medium term  

initiate a Degree programme in midwifery in collaboration with international midwifery experts, till own faculty is ready to take over 4th year in a General Nursing Diploma Programme could be upgraded to a Post Basic Diploma/1st Year BSc Post RN and later to a BScM Programme. This way these candidates can take the core elements of a BScN programme and also have the advantage of specialist midwifery training in order to justify the award of a BScM.

Long term  

initiate a Masters Programme in midwifery in collaboration with international midwifery experts, till own faculty is ready to take over long term planning should envisage midwives practicing in hospitals and medical clinics, and also assist deliveries in birth centers and at home.

Lady Health Workers 5.33 OVERVIEW The Lady Health Workers programme is a National programme with Federal funding and is implemented within its own framework and operates largely as a vertical programme. Day to day operational decisions are taken at the provincial and district levels for efficiency. At the provincial level there is a Provincial Coordinator and a Provincial Programme Implementation Unit to oversee the programme supported by District PIUs and LHW trainers and supervisors. The LHW and LHWSs are not part of the formal structure of the health department and therefore standard service rules and regulations and BPS pay scales do not apply to staff of this programme.

5.34 RECRUITMENT PROCESS

Recruitment is aimed largely at local women, all residents of the community in which they work. Selection criteria includes, a minimum of eight years education, a high school certificate, preferably married, aged between 18 to 45 years and the candidates must be recommended by the local community. The usual procedure for recruiting LHWs is quite lengthy involving both the PPIUs and the DPIUs. Applications are received by the medical officer of the health facility where the LHW will work. A selection committee comprising the medical officer, the LHV and/or the Dispenser of the facility and a local person of standing or elected representative of the area/community in which the LHW will work is convened for the interview and selection process. The appointment letter is authorised by the EDO health. The selection and recruitment of LHWS is similar with the inclusion of the District Coordinator and the EDO health in the selection committee. The LHWs are on one year contracts, extendable each year with a current annual increment of RPs. 100/With further extension of the programme planned rapid, transparent and effective recruitment mechanisms will be required.

5.35 RETENTION

Retention of LHWs varies considerably across districts, tehsils and communities. The turnover of LHWs is quite high in some areas; reliable data is not readily available.

5.36 ANALYSIS â&#x20AC;&#x201C; RECRUITMENT AND RETENTION

5.36.1 Recruitment and Retention Analysis of the recruitment of LHWs indicates that one of the key factors influencing recruitment is political interference at the local level. This results in the recruitment of women who do not necessarily meet the criteria for selection, particularly in terms of educational requirements. As a result LHWs are being employed who do not have the capacity or aptitude for the work which is then also compromised.

5.36.2 Contract System Employment on one year extendable contracts is influencing factors such as commitment and motivation. Similarly with a current annual increment of 100 rupees only this does not provide much of an incentive for a longer term commitment or any incentive to perform well. Retention is also compromised due to delays in the payment of salaries; salary payments have at times been delayed for months. This is fuelling frustration and lack of motivation.

5.36.3 Remuneration Package Salaries themselves are too low; the current salary of the LHW is around RPs.3, 500/- per month and that of the LHS RPs. 4, 500/- per month. This is well below the national recommended minimum wage. There are no incentive protocols in place currently.

5.36.4 Support Mechanisms Support for LHWs is good in areas where the BHU and RHC are functioning well and fully staffed with LHVs and female doctors. Monthly meetings are convened providing an opportunity for discussion and feedback. This may not be the case in areas where the FLCFs are not so well staffed or well functioning. This then compromises the support available for the LHW leading to feelings of isolation professionally and de-motivation.

5.36.5 Lack of Supply Items Compromising Retention Evaluation findings24 indicate that in many instances LHWs were seriously under-supplied with drugs and contraceptives thereby compromising their work significantly. This impacts motivation and frustration levels leading to high rates of attrition in some areas. 5.36.6 Lack of further educational opportunities and promotion options There is a complete lack of further skill development opportunities and educational opportunities for LHWs. This is a deterrent for high performers to continue in the service.

5.37 PROPOSED KEY STRATEGIES – RECRUITMENT AND RETENTION OF LHWS

Key Challenge: Recruitment and Retention of LHWs Short Term:       

scale up recruitment ensure recruitment protocols and mechanisms are applied ensure recruitment criteria applied ensure supplies are provided on time strengthen support networks improve remuneration packages review contracting system; explore options for longer term contracts

Medium Term:   

incentives for high performers including further educational opportunities develop synergies with MNCH and nutrition programmes provide additional training for skill enhancement

Long Term: 

develop credit system as a basis for proceeding on to paramedic and nurse training

Third party evaluation 2002, commissioned by the MOH and funded by DFiD

Paramedics 5.38 OVERVIEW As indicated in Section 2 a comprehensive study into the service structure, rules and regulations for paramedics has recently been completed. Implementation has been approved and initiated. In the light of this study it would be unnecessary repetition to repeat the process here therefore only the key issues pertaining to recruitment and retention are mentioned here.

5.39RECRUITMENT

Recruitment for paramedics over the past twenty five years appears to have been largely haphazard, without need based planning. This has often been in response to a new type of health facility, model of care and vertical programming e.g. EPI, TB control, Malaria control There are variations in the educational requirements for recruitment, even for the same posts. Similarly for BPS Grades following recruitment; there is no uniformity of pay scales. Under the re-structuring it is proposed that the current recruitment and admission criteria be enhanced to FSc. From matriculation as the basic entry qualification. For post basic the diploma courses should be upgraded to two year programmes.

5.40RETENTION

As with other cadres of health staff, particularly those posted in rural areas, levels of absenteeism are reportedly high; so too is de-motivation and frustration. Additionally, in the absence of a clearly defined career progression protocol retaining high performing paramedic staff is a challenge.

5.41 ANALYSIS â&#x20AC;&#x201C; RECRUITMENT AND RETENTION

The key issues affecting recruitment and retention of paramedics have been well documented in the re-structuring report earlier referred to. In summary after many years of neglect this group of health workers are frustrated, demotivated and anxious for change. The potential is great and as in many other countries Allied Health Workers, often the more regular nomenclature of paramedics, enjoy substantial prestige and recognition within the health system.

5.42 PROPOSED KEY STRATEGY â&#x20AC;&#x201C; RECRUITMENT AND RETENTION OF PARAMEDICS

The proposed strategy is to implement the re-structuring recommendations without delay to be followed by a review process within the next three years. Further adjustments may be made depending upon the outcomes of the present re-structuring process. Basic entry qualifications to be enhanced to FSc.

100

Performance Management SECTION SIX

101

6.1 PERFORMANCE MANAGEMENT - GENERAL OVERVIEW Performance management is one of the key and most important HR functions for any organisation. It is inextricably linked to general people management. Managing people is a complex matter in itself. Effective performance management is a holistic process intended to support both the individual in their growth and development and achievement of key performance indicators and objectives. Likewise for the organisation in terms of organisational achievements, growth and development; the two must be mutually enhancing. Performance management is as much about managers effectively managing as it is about individual performance. It should be strategic keeping in view the longer term goals and integrated in that it links individuals, teams and the organisation. It is a process, part of a continuous cycle involving not only the staff member but also colleagues and at times the community or end users, which contributes to the overall performance of the organisation in order to achieve high levels of success. It is intended to be supportive, objective and to provide constructive on-going feedback and it is applicable to all employees at all stages in their career cycle. Evidence has indicated that salary levels1 and incentives influence performance as well as recruitment and retention. Likewise effective performance management systems increase job satisfaction, promote personal growth and create a stronger feeling of commitment to the employing institution.

6.2 PERFORMANCE MANAGEMENT IN PUNJAB

The current system for performance evaluation is the Annual Confidential Report. There are three variations to the ACR depending upon the Grade of the staff; UF-50 for Grade 16 and above; UF-45 for Grades 5-15 and a further un-numbered form for Grades 1-4.The form is further sub-divided into sections for completion both by the assessor and the assessee to review such areas as personal profile, duties performed, training received, medical checkups, attitude, knowledge of Islam and several others. The rating is based on an alphabetical grading system – A to D with A being „good‟ and D being „poor‟, which is based almost entirely on the subjective judgement of the person completing the form and relates primarily to personal attributes in a generalised way rather than to a specific role, job description, set of objectives or responsibilities. The forms themselves are complex, and would benefit from being more user-friendly. The annual performance reports of officers posted in the district are initiated by the Zila Nazim in respect of the District Coordination Officer and are counter-signing by the Chief Secretary. For performance evaluation at the senior level the DCO initiates the Annual

Merlin 2008

102

Confidential Review of the EDOs and is also the countersigning authority of the ACRs of District Health Officers initiated by the EDO2. For all other grades and cadres the reporting officer is expected to complete and sign off the ACR. Currently most staff do not have an updated, relevant job description, the basis for any performance review process. The recent development of standard job descriptions under the Punjab Devolved Social Services Programme3 provides an excellent opportunity for this to be addressed. Roll-out and institutionalisation of these job descriptions in itself requires a focused HR input. The completion of the ACR is primarily seen as an arduous task to be undertaken by both parties and then only if required i.e. when applying for another posting, promotion or transfer. The completion of the ACR is rarely done through joint discussion and review rather it is done by the employee seeking out the authorised person to complete the document. The ACR does not meet any internationally accepted protocols for effective performance management nor does it serve to achieve high levels of performance for the individual, the manager or the organisation.

6.3 LINE MANAGEMENT

In terms of line management of staff as a basic human resource function for day to day operations, work planning, performance management and staff development line managers are generally ill-equipped and un-trained in this aspect of their work. This is impacting on the performance of staff and thereby the quality of health care service delivery. This is further evidenced by non completion of annual confidential reviews, lack of accountability, the absence of staff development plans based on real need and high levels of absenteeism as indicated elsewhere in this report. It is recommended that as part of the development of a comprehensive human resource department, also being recommended in this report, further input is required to assess the needs and recommend more specific inputs to address the whole issue of people management. This should be undertaken from two perspectives, a) job roles and responsibilities in terms of line management and b) training needs for line managers to enable them to fulfil this crucial part of their responsibilities.

Punjab Local Government Ordinance 2001 Job Descriptions and Performance Evaluation Criteria; PDSSP 2008/9

103

TABLE 19: A MODEL FOR ROLES OF MANAGERS AND EMPLOYEES IN PERFORMANCE MANAGEMENT Managers/Supervisors Talk regularly to employees about their work and their role in work area priorities Involve everyone in negotiating priorities Conduct regular planning and progress meetings Give feedback regularly on items of work and discuss progress Tell everyone what you look for when monitoring performance Talk to everyone about the types of work they like to do Ensure everyone is clear about his or her responsibilities and accountabilities Ask every one for feedback and act upon it Acknowledge jobs well done and celebrate successes Keep everyone informed about broader issues that affect them Support everyone to learn from mistake Coach and train them and provide resources to help everyone Learn from everyone experiences Develop an environment where everyone feels safe to exchange feedback Ensure common themes in teamâ&#x20AC;&#x;s performance management are a regular agenda item at team meetings

Employees Take an active interest in what is happening in the health sector Ask for information about priorities and how your work contributes Seek and be open to feedback about performance Participate constructively in meetings and discussions Openly discuss progress with your supervisor Look for opportunities to develop skills Find ways to help other team members do their jobs better Attend relevant learning & development activities Raise concerns about issues affecting performance in a constructive manner

Source: People and Strategy 2006

104

Doctors 6.4 PERFORMANCE MANAGEMENT - CURRENT SITUATION IN PUNJAB

The Annual Confidential Report is the basis for performance evaluation of all doctors in the Punjab health department in line with all other government departments. This is essentially an annual review process based largely on subjective evaluation of the person without the support of a current job description or key performance indicators. Currently there is a massive back-log of non-completed ACRs for doctors spanning more than twenty years. The health department recently posted lists of names on their website to try to encourage doctors to come forward and update their data and have their ACRs completed. To date the take-up of this option remains negligible.

6.5 ANALYSIS OF PERFORMANCE MANAGEMENT – DOCTORS

The Annual Confidential Report as the basis for performance management is rather outdated, not user-friendly and highly subjective. The application is less rigorous than required, largely ineffective and in many instances never applied. Additionally, it has no real base from which to review performance as key performance indicators are not developed, job descriptions are usually not available and rarely are work plans or similar tools used as a means to review performance outcomes. Significantly, line managers are not trained in how to conduct performance reviews and they themselves are subject to the same ineffective, subjective protocols. Similarly, reportees themselves have little understanding and no experience of the benefits, value and utilisation of effective performance management.

6.6 REWARD AND RECOGNITION

In the absence of a transparent, effective performance management protocol good performance goes un-noticed and poor performance likewise. There seems to exist a general perception that a good ACR is dependent upon „affiliations‟ rather than performance. The ACR is more likely to be based on the relationship between the staff member and the manager rather than actual performance. The current process does not address competencies and capacity. Additionally, the tendency is to give „safe‟, average ratings as these do not require the line manager to share the ACR with the staff member. Adverse comments and below average ratings requires that the line manager shows the completed ACR to the staff member. The 105

staff member then has the right to appeal and the line manager may not be in a position to defend the rating. This may and at times does lead to confrontation and even litigation. It also reinforces the use of average ratings.

6.7 JOB DESCRIPTIONS

Job descriptions for doctors have been developed in the past and more recently also however key respondents indicated that they rarely see a job description. The knowledge of their roles and responsibilities is mostly handed on verbally. Additionally there are no defined objectives or performance indicators against which to measure performance. The lack of rigorous application of the ACR system is seriously affecting the professionalism and accountability of doctors which is directly impacting upon the delivery of health care services. Experienced, motivated doctors with leadership potential are not being supported in terms of their professional development and learning needs to enable them to progress further. Consistently good performance is not being recognised and rewarded. Likewise, doctors of average or below average performance continue without remedial action and identification of learning needs. This has an impact on retention and staff motivation.

6.8 PROPOSED KEY STRATEGIES – PERFORMANCE MANAGEMENT OF DOCTORS

Key challenge: Performance management is ineffective, lacks transparency and varies widely in its application The key objective is to institutionalise effective, transparent performance management at all levels. Short Term:   

    

conduct a comprehensive review of the current ACR framework with a view to developing a new protocol based on modern performance management systems development and application of a transparent, user-friendly performance management framework supported by guidelines for all users introduction of recognition and reward systems for good performance; these may be simple non-monetary incentives such as, doctor of the month; health facility of the month; letters of appreciation translate the document into Urdu for ease of access for all grades make job descriptions available for all staff as a basis for performance management performance to be a key criteria for promotion translation of the document into Urdu for ease of access of all levels of staff institutionalise annual PM review sessions with agreed objectives and KPIs 106

Medium Term:  

   

further adapting or improving upon performance management strategies to influence staff motivation training for line managers in effective performance management orientation for all staff on the utility of performance management copies of all ACRs to be filed in personal files in a central HR department for accessibility as and when required put effective mechanisms in place to support corrective action for poor performers – disciplinary procedures develop on-line access for PM forms; facilitation of preparation for a performance review session

Long Term:  

review the PM protocol; revise and update as necessary to ensure best practice develop a more comprehensive PM tool based on 360 degree protocols particularly for senior managers

Key challenge: Lack of accountability at all levels The key objective is to make all staff accountable for their actions, roles and responsibilities Short Term:   

use of PM protocol to hold staff accountable for their actions and performance development of HR policies and procedures to support PM protocol including disciplinary procedures job descriptions available for all staff

Medium Term: 

all doctors to have an annual performance review based on the new protocols

It is recommended that a comprehensive review of the current ACR framework must be undertaken if this is to be adapted for effective performance management. The recommended, preferred option would be to develop a completely new framework based on best practice and modern protocols for performance management. It is proposed that this would need to be developed in a phased manner over the short to medium term and further reviewed in the long term. The first phase would be a comprehensive review of the ACR framework.

107

6.9 DEVELOPMENT OF A PERFORMANCE MANAGEMENT SYSTEM

The performance management system must be strategic using the job description as a baseline supported by key objectives, performance indicators and long term goals. The performance management of doctors, as with other health professionals, must be a process not an event. Performance management must be part of a continuous cycle based on organisational, departmental and/or unit goals from which personal goals and objectives are drawn. It is against these that performance is reviewed and development plans made. This must be supported by on-going monitoring and two-way feedback with, as a minimum, annual review. The framework should be supportive and flexible in order to facilitate and not obstruct how staff work and operate. It must be a tool to ensure that managers manage effectively and that staff know and understand what is expected of them. Also that staff have the skills and ability to deliver on those expectations, are supported by the line manager and the organisation to develop and grow and enhance their capacity for career progression. Staff must be given feedback on performance and have the opportunity to provide feedback. Likewise, staff must be able to discuss and contribute to individual and team objectives and the performance of the organisation. The protocol must be uniformly applied to all levels of staff. Annex 11 indicates the key elements required of a performance management system.

6.10 DEPLOYMENT OF A PERFORMANCE MANAGEMENT SYSTEM

Simultaneously it is important that all staff and managers are made aware of the value and purpose of meaningful performance management. Guidelines need to be developed and shared with all staff in orientation sessions on how to prepare for a performance review and how to conduct a performance review. Learning opportunities will also need to be developed and provided for all line managers to teach them how to conduct meaningful and effective performance reviews.

108

Nurses, Midwives and Lady Health Visitors 6.11 PERFORMANCE MANAGEMENT - CURRENT SITUATION IN PUNJAB

Like doctors, Annual Confidential Review forms the basis for performance evaluation of all nurse professionals. Currently in Punjab the vital link between job descriptions and performance management is not clear to even the senior nurse professionals and they have never had any formal training in this context. ACR are recorded for nurses but LHVs and midwives, in the absence of a career leader are little interested in having their annual evaluation being done. Majority of the nursing staff seem unaware of their job description and what their performance indicators are. During the focus group discussions and the consultative workshops, the nurses expressed keen interest in undertaking formal training on performance evaluation and how the whole mechanism stems from the job descriptions.

6.12

ANALYSIS - PERFORMANCE MANAGEMENT

6.12.1 Performance Management System and its Acceptance The performance management system that presently exists has no laid out guidelines. It is being conducted with flexibility of having the ACRs signed by authorities who have not directly supervised the performance of the concerned nurse for the time period for which she is being evaluated. Generally the existing system is held in contempt by nurses at all levels. The annual ACRs are often delayed and there is no centralised office for monitoring the performance evaluation process and timely submission of ACRs by the concerned authorities. For LHVs as well the Annual Confidential Report is the mechanism used for performance review on a yearly basis. Due to the lack of a career structure, there is little interest in documenting the ACRs. There are no specific performance indicators related to the job specification and TORs of LHVs. Acquiring additional qualification or undertaking courses in related fields is also not acknowledged in the annual review. The ACR for pupil midwives is under the concerned MS. These are than countersigned by the DGN or the principal of a medical college who has not actually supervised the performance of that Pupil Midwife over the last one year for which he/she is evaluating her. 109

6.12.2 Understanding of the Punjab Health Department’s Directions and Priorities The nurses, LHVs and midwives are uncertain about the health department‟s directions and priorities. There is inaccurate or ambiguous information about current initiatives being undertaken by the health department. It was felt that at different levels, nurses receive inconsistent messages from their supervisors. 6.12.3 Job Descriptions Job descriptions have been developed but are rarely handed over or explained to the concerned staff member. Job descriptions were found to be inappropriate with no defined performance indicators. Very few nurses were found to have received a job description and fewer were ever explained the performance indicators on the basis of which they will be evaluated. The existing job descriptions are found to be related to professions and not to posts. Neither are there any periodic counselling sessions to help the nurses achieve optimal performance against the indicators defined in their job descriptions. 6.12.4 Rewards and Recognition Good performance is rarely acknowledged. A good ACR is awarded even when the performance is poor due to personal connections and political influence. A general perception is that the “wrong” people are rewarded.

6.12.5 Career counselling There is no formal arrangement to provide any career counselling to aspiring nurse professionals

6.12.6 Feedback about performance Feedback received by nurses, LHVs and midwives from their supervisors was found to be either infrequent or destructive to motivation. Much feedback about performance problems is ambiguous, implies blame or produces hostility.

6.12.7 Response To Poor Work Performance Poor performance is often ignored. When it is addressed, the most common solutions are to move the person. Communication about problems is directed to all staff rather to the one specifically involved. Causes of poor performance are never assessed. Individual nurses, LHVs and midwives are considered to be responsible for their own poor performance and systemic issues impeding their output are not considered.

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6.12.8 Trust in managers’ treatment of staff Many senior nurse managers are seen as having poor intentions and being incompetent. Most staff do not seem to trust them to provide fair and well informed assessments of their performance. It is common to hold the supervisors as being unfair and favour the non deserving on the basis of personal contacts.

6.13 PROPOSED KEY STRATEGIES

Short Term: 



 

an operations research to identify motivating factors among nursing workforce and to determine whether the existing performance management activities were appropriately implemented the current performance evaluation system should be reviewed and assessed for:  possibility of introducing certain interventions to improve the performance of nurses  adapting or improving upon performance management strategies to influence staff motivation reviewed performance management system should be institutionalised for all levels of nurses and cadres, with detailed forms and guidelines for the users performance measurement methods must be developed to:  set realistic achievement targets,  measure progress towards these targets and  hold senior nurse professionals accountable for their actions in achieving targets



define critical technical and behavioural competencies for different levels of nursing cadres  develop and set standards for nursing, LHV and midwifery practice  job descriptions to be reviewed and performance evaluation criteria established based on yardsticks driven from the job description of nurses in various cadres and on the competencies defined for various levels of nurse cadres  senior nurse professionals to receive formal, institutionalised training on drafting job descriptions and their link to annual performance evaluation  performance evaluation forms to be developed to assess performance on yardsticks derived from the individuals‟ job descriptions.



all nurses appointed to receive the job description in the first week and explained the indicators on the basis of which their performance will be evaluated at the end of term. This is to help them develop a thorough understanding of their roles as well as their contribution to the overall mission of providing quality healthcare for all.

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

  

developing and using these nursing workforce performance indicators to improve performance management mechanisms effective performance to be recognized through an institutionalizes reward and recognition mechanism a unified, transparent performance evaluation system to be established and its implementation monitored facilitate access and capacity building of all concerned to tools for assessment

Medium Term 

establish a centralised human resource department in the DGH office to regulate performance evaluation on annual basis copies of all ACRs to be stored in personal files in a central HR department for accessibility as and when required mechanism to hold all faculty and staff accountable and to reward individual and team performance where appropriate. With this strategy, managers would be able to provide feedback and coaching to employees in a more effective and timely manner balanced and valued feedback to be given periodically through a formal feedback mechanism a mechanism should be established to analyse performance and provide managers and policy makers with subsequent information to make appropriate nursing workforce decisions

 

Long Term 

Review of the performance management mechanisms for nurse professionals in international setting and update the existing ones on an ongoing basis

Reasons for poor performance and motivation • • • • • • •

Staff shortages, Low salaries, Poor working conditions. Lack of transparency in human resource management practices, Limited supervision and monitoring, Weak disciplinary procedures and Limited and slow opportunities for promotion

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Lady Health Workers 6.14 CURRENT SITUATION - PERFORMANCE MANAGEMENT FOR LADY HEALTH WORKERS

Lady Health Worker Supervisors are appointed on contract as the direct, day-to-day supervisor of the LHW. Each LHWS is responsible for supervising between 20 and 25 LHWs. The LHW Supervisor may be a graduate and/or a Master degree holder, a nurse or an LHV and will receive one year‟s training. The supervision of LHWs is done at field level for which transport is essential. Performance is largely measured against numbers of referrals, meetings conducted and patients seen. It is primarily quantative in nature focused on numbers rather than quality and outcomes. The numbers form part of the DHIS reporting procedure and not staff development. Assessment of competencies and ability are not part of this supervision process. There is no standard performance management protocol for LHWs and LHWSs.

6.15 ANALYSIS – PERFORMANCE MANAGEMENT

Effective supervision and performance management is a major challenge for the LHW programme.

6.16 MOBILITY OF LHW SUPERVISORS

Many LHWSs are at times without transport for long periods due to non availability of vehicles and/or funding for POL. It is extremely difficult for the LHWS to supervise 20-25 LHWs if she is unable to meet them regularly and assess their performance in the community. Adequate budgeting for transport costs is an on-going challenge. Additionally, the LHWSs lack skills and expertise in effective, supportive performance management; the focus is more on a „check-list‟ approach. The LHW Supervisors in turn lack supportive supervision and performance management that would enable them to grow and develop.

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6. 17 PROPOSED KEY STRATEGIES – PERFORMANCE MANAGEMENT OF LHWS

Key Challenge: effective performance management system for LHWs and LHWSs

Short Term:    

consult with LHWs and LHWS to determine the best options for performance management develop and implement an appropriate transparent, user-friendly performance management framework translate the document into Urdu for ease of access ensure availability of transport for LHWSs

Medium Term:    

train LHWSs in how to conduct the new management performance protocol orientation for LHWs on the utility of the PM protocol put effective mechanisms in place to support corrective action for poor performers – disciplinary procedures develop and implement a PM system for LHWSs

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Paramedics 6.18 CURRENT PARAMEDICS

SITUATION

PERFORMANCE

MANAGEMENT

FOR

All cadres of paramedics are subject to the same ACR process as the doctors and other health care professionals. As with the doctors the application of the ACR protocol is sporadic and varies widely in its application. Thousands of ACRs are not completed. Recommendations for performance management made for doctors apply equally to paramedics. It is further recommended that the application of performance management for paramedics should be made within the revised service structure. Institutionalisation of performance management should be an integral part of the restructuring process and will support and help to determine revised BPS Grades, roles and responsibilities and learning needs.

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Promotion Section Seven

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7.1 PROMOTION â&#x20AC;&#x201C; GENERAL OVERVIEW

Promotion of staff is good for staff, vital for the organisation and of great benefit for the end users. Promoting staff from within any organisation is highly motivating. It is also good business sense; it is much more cost effective to promote staff whenever possible rather than to opt for external recruitment. Transparent and effective internal promotion policies firmly grounded on good performance and merit generate organisational loyalty, retain institutional memory and boost staff morale. Needless to say promotion policies that are not transparent and founded solidly on performance and merit have quite the reverse effect on staff morale, confidence in the organisation and loyalty. Additionally, organisations that promote from within demonstrate to staff that their work is recognised and good performance rewarded which is a strong tool for retaining top talent. Promoting existing employees into more senior roles and positions may also reduce the learning curve for new staff into a position which ultimately supports productivity and reduces training costs. Lack of an effective, merit based promotion structure supported by an effective performance management system leads to frustration, poor performance and lack of accountability. All of which impinge upon absenteeism, quality of care, level of job satisfaction, career choice and general overall commitment to the employing organisation. These factors whilst important in their own right added together result in high levels of dissatisfaction, frustration and poor quality service delivery. The key purpose of promotion is to provide opportunities for growth and development within the organisation and career progression for suitably qualified staff clearly demonstrating potential for upward mobility. The promotion policy must be designed to provide equal opportunities for all health department staff.

7.2 Promotion in Punjab

Currently the Punjab health department operates the standard government BPS grading and scale system for promotion of all health staff. It is based primarily on seniority i.e. number of years of service rather than merit and performance assessment protocols. Promotions may only be made following the announcement of a vacancy when eligible candidates may apply. Service rules do not necessarily support health professionals with higher degrees in attaining promotion; e.g. in nursing having a Bachelor Degree does not earn any credits for promotion. As with most HR functions one of the key factors of promotion is transparency. Without this the process becomes meaningless and serves to generate frustration, distrust and demotivation within the organisation. A misguided promotion process will also create problems for senior managers and the credibility of the organisation.

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In recent years it would appear that transparency in promotion, as in other HR functions, has become an area of increasing concern for staff and managers within the Punjab health department. Promotion must be based on good performance, merit, supported by modern, transparent service rules and regulations and this in turn must link directly to the performance management of all health staff at all levels.

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Doctors 7.3 AN OVERVIEW OF PROMOTION OF DOCTORS Promotion links to people development i.e. continuing professional development, continuing medical education and other training and learning opportunities. This section will also include some aspects of these for completeness.

7.4 PROMOTION â&#x20AC;&#x201C; CURRENT SITUATION IN PUNJAB

Seniority lists for doctors are prepared based on the number of years service from the date of selection by the PSC. This is then coupled with the PSC merit list prepared at the time of selection i.e. the doctor at the top of the merit list by scoring highest in the PSC examination and selection process and with the most number of years service will be considered the most senior. This is intended to then link with the ACR protocol to determine performance in the intervening years between recruitment and promotion. This rarely happens. There is a four tier promotion protocol for doctors in the general cadre starting at Grade 17 i.e. Medical Officer, Senior Medical Officer, Grade 18, Assistant Principal Medical Officer Grade 19 and Principal Medical Officer Grade 20. Similarly for the teaching cadre starting with the Demonstrator at Grade 17, Assistant Professor Grade 18, Associate Professor Grade 19 and Professor at Grade 20. If promoted the salary will be increased and fixation will be in the new Grade. This is separate to the normal annual increments. Promotion however is only possible if vacancies occur which are then posted to invite applications. Currently there is a fixed formula for the number of doctors in each Grade per 100 doctors. Table 20 gives the formula.

TABLE 20: PROMOTION FORMULA FOR DOCTORS

GRADE

Medical Officer (17) Senior Medical Officer (18) Asst. Principal M.O. (19) Principal M.O. (20)

NUMBER (PER 100 DOCTORS) 50 35 14 1

SAMPLE NUMBER BASED ON 10,000 PRACTICING DOCTORS 5,000 3,500 1,400 1,000

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For the most part doctors do not have any clear career pathway or promotion opportunities based on performance, qualifications, skills and experience.

7.5 ANALYSIS OF PROMOTION - DOCTORS

While there is a government BPS grading and scale system operational within the health department of Punjab for doctors, as also other staff, it is widely acknowledged that it lacks transparency and varies significantly in its application. Additionally, as promotion is not based on an effective performance management system it lacks credibility. Doctors are paid in accordance with standard Basic Pay Scales of the government with entry at BPS Grade 17 and promotion possibilities up to Grade 22. Promotion is subject to availability of posts according to a pre-set formula as shown in Table 20. Basing promotion primarily on seniority rather than merit and performance assessment protocols is weakening the human resource base of the health department. High performers are not coached and mentored for promotion while at the same time consistently poor performers are being promoted. It is also widely acknowledged that promotion is often made based on affiliations, professional, social or political, thereby negating accountability mechanisms. These issues are further compounded by the fact that doctors are frequently transferred for a variety of reasons which may or may not include promotion. For those doctors who have been working for many, many years without promotion and/or opportunities to improve their qualifications this becomes increasingly frustrating and demotivating further adding to the issue of retention. In the absence of an effective performance management system, based on job descriptions and performance objectives there is no mechanism for consideration of competencies or capabilities in relation to promotion. There is no formal requirement to undertake additional training, CPD or any other professional development activity to support promotion into the next BPS Grade. Similarly there are no leadership development programmes available for senior doctors; likewise limited opportunities to undertake senior management development programmes either of which could be counted as credit hours for professional development and annual reregistration. Promotion to the next Grade is supposed to be based on the submission and review of all ACRs and not only that ACR relevant to the period under consideration for promotion. This is flawed in two ways; 1) the ACR is not an effective or transparent system for performance management and is rarely completed and 2) the requirement to submit all ACRs for promotion purposes is extremely cumbersome and irrelevant as past ACRs, if completed, had already been reviewed and taken into consideration at the time of the previous promotion.

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There is no clearly defined career structure for doctors other than simply moving up the BPS scale from Grade 17 as an MO/WMO; Senior MO/WMO Grade 18; Asst. Principal MO/WMO Grade 19 and Principal MO/WMO Grade 20. Similarly for those doctors moving into the teaching or administrative cadre minimum qualifications and educational requirements are not readily available. There is no requirement for doctors to undertake CPD or CME to remain updated in clinical practice. Similarly there is no requirement for doctors to re-register with PMDC for continuation of practice or promotion.

Promotion – Key Challenges • • • • • • • • • • •

Lack of transparent, efficient mechanisms and protocols Varied application of basic protocols for promotion Lack of effective human resource planning Lack of effective performance management Lack of person specifications for key posts Job descriptions generally not available or referred to Lack of career pathways No clearly defined professional requirements for each level of promotion Limited opportunities for professional growth and development Ineffective people management No requirement to re-register with PMDC for fitness to continue practice

7.6 Proposed Key Strategies – Promotion of Doctors

Short Term:     

 

all doctors to be promoted following established protocols and procedures promotion to be based on effective and transparent performance management protocols job descriptions to be made available to all staff and all line managers person specifications to be available for each post/JD clarification of post graduate or other qualifications required for each level of promotion; promotion must be linked with the attainment of higher qualifications and/or training/publications establish PMDC protocols for annual re-registration of doctors; to include x number of hours CPD/CME update the service rules for doctors to include annual re-registration with PMDC as mandatory 122



develop a clear career structure and pathways with experience/educational requirements clearly identified for each level

Medium Term:        

CME and CPD opportunities strengthened to support promotion requirements accreditation of CME requirement to demonstrate x number of hours CPD for re-registration with PMDC annually PMDC re-registration requirements updated to meet emerging trends provide incentives for high performers develop ‘fast track’ promotion opportunities for high achievers revise and update doctors service rules to include annual re-registration with PMDC as mandatory for continuing practice revise service rules in accordance with updated career structures

Long Term: 

all service rules for doctors updated to reflect updated standards for promotion and annual re-registration with PMDC

7.7 PROMOTION STRATEGY

It is recommended that a fully integrated promotion framework is developed for doctors. This would utilise standard assessment, performance and behavioural tools to assess the performance of the doctor seeking promotion. These tools would also support the line manager assessing and approving the promotion. Additionally, qualifications and minimum post graduate training and/or CPD hours required for each level of promotion should be clearly identified and documented as key requirements for. The number of years experience could be just one of the criteria. For those doctors choosing to move into the teaching or administrative cadre there must be minimum educational requirements clearly identified and used as one of the criteria for eligibility for promotion i.e. a doctor wishing to become a demonstrator must first of all be prepared to take a practical demonstrators teaching course; likewise a doctor wishing to become an administrator must first take a basic administrators course. Subsequent promotion would be based on the attainment of further qualifications and in the case of the teaching cadre the number of publications and/or academic papers produced, in the same field. In order to encourage doctors to further their professional growth, particularly when they move into the teaching or administrative cadre, they could be offered promotion if all other criteria are met, on the proviso that they complete a management course or a teaching course subsequent to which their promotion would be confirmed. This would not only stimulate professional development but would help to fill vacant posts in these cadres.

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Annual re-registration with PMDC should be made mandatory for all doctors. The criteria for re-registration must be based on pre-determined protocols i.e. number of hours of CPD; additional qualifications as appropriate. A minimum of 35 hours CPD with documented evidence should be the minimum acceptable criteria for re-registration for continued clinical, management or teaching practice. The Pakistan Medical Research Council has already undertaken work in terms of the development of career structures for health professionals under the ‘Draft Career Structure for Health Professionals, National Commission on Career Structure for Health Professionals, Feb 2008’. Following completion of the structure for doctor’s implementation must be a priority. Key requirements for a promotion strategy are described in Annex 12.

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Nurses 7.8 Promotion of Nurses â&#x20AC;&#x201C; Current Situation in Punjab

As the nursing profession became more organised and regulated, the requirement for appropriate, transparent and equitable rules for recruitment and promotion became apparent. It was the Province of Punjab that took up leadership in the development of service rules for the profession in 1955. Gazetted status was given to nurses in1960 for the administrative and teaching positions. In the early 1980s, the grade for the general staff/charge nurse was raised from BPS 11 to 14 and again up-graded the initial posting scale of Charge Nurse from 14 to 16, making them gazetted officers with the title of Nursing Officer. All incumbents in BS-16 were also awarded promotion to BS-17. This situation has resulted in seniority issuesâ&#x20AC;&#x201C;especially amongst the nurses who were already in BS 17 or above. Currently a new career structure for nurses, developed by the Pakistan Medical Research Council through extensive stakeholder consultations, is under consideration. The nursing cadre is a unified cadre, comprising of interchangeable positions of management and teaching at senior levels. There are five stages of pay scales of incumbents, ranging from 16 to 20. Acquiring two yearsâ&#x20AC;&#x2122; Diploma in Nursing Management and Education is a prerequisite for promotion to BPS 17. No further addition of qualification, or in-service training, is required for promotion to grades higher than 17. The only criterion is seniority-cum-fitness, i.e. length of service with good annual confidential reports. At that time of the development of service rules the eligibility criteria for promotion only considered seniority and no weightage was given to specialised higher degrees. The concept of nursing education was limited to only post-basic diploma in colleges of nursing. At present no mechanism exists for consideration of competencies or capabilities for upward movements in the profession. This disincentive for higher achievement is proving itself as a barrier and needs to be addressed. There is a need to harmonise nursing and midwifery educational programmes with the rules and regulations for career structures as well as the accreditation systems in the country.

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7.9 BASIC PAY SCALE

Almost all cadres of health professionals are paid in accordance with standard Basic Pay Scales of the government and promotion is subject to availability of posts. Whereas the career structure should be based on performance, required experience and qualification and de-linked with the availability of the posts. The best example of this application is the Pakistan Atomic Energy Commission in which a professional need not to wait for availability of a post and promotion up the career ladder is based on performance and experience. Currently nurses are grouped under five sub groups working from BPS Scale 16 to BPS Scale 20: Designation

BPS Scale

Staff/Charge Nurse

Head Nurse

Deputy Nursing Superintendant Nursing Instructor College of Nursing Clinical Nursing Instructor Asst Nursing Instructor Asst Director Nursing, Principal School of Nursing, Nursing Superintendant, Controller Nursing Examination Board, Nursing Instructor College of Nursing

Principal School of Nursing, Teaching Hospitals and DCNS, Deputy Director Nursing

Director General Nursing, Chief Nursing S Superintendant, Principal Mayo Hospital Lahore (2), Principal Jinnah Hospital CON, Principal Services Hospital CON

Promotion for nurses in Grade 18 and above is on the basis of seniority窶田um fitness. For Grade 16 and 17, 1/3rd of the positions are filled through initial recruitment and the remaining through promotion on the basis of seniority窶田um fitness. Details attached in Annex 13. Credit is given to nurses possessing Diploma in Teaching and Ward Administration or equivalent qualification recognised by the PNC.

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7.10

ANALYSIS OF PROMOTION

The BPS Scale of Charge Nurse has been upgraded from BPS 14 to BPS 16. The BPS Scale of Head Nurse, Deputy Nursing Supt. And Nursing Instructor College of Nursing has been revised and upgraded from BPS 16 to BPS 17. BPS 17 now has these three as well as the Clinical Nursing Instructor and Asst Nursing Instructor whose grade has not been revised from BPS 17. This has led to frustration among the senior nurses as the power distance between them and their juniors has been reduced and moreover they have no career rules or training courses to help them climb up the career ladder and move into the next tier. After securing promotion in BPS 17 on the basis of the Diploma in Nursing Management and Education, no further training or addition of qualification is required for promotion to higher grades. The only criterion was seniority-cum-fitness, i.e. length of service with adequate annual confidential reports. Promotion to the next step requires submission of all the ACRs rather than that relevant to the period under consideration for the next promotion. This is not only cumbersome but also irrelevant as these ACRs had already been reviewed and take into consideration at the time of previous promotion. There is no formal, institutionalised, training programme available for senior nurses to develop their leadership capabilities and earn credit hours of professional development. There is a strong need for development of a sound career structure for health professionals in the country to improve efficiency, discourage migration of scarce commodity of health professionals to other countries and above all to meet the health challenges to achieve the United Nation’s Millennium Development Goals.

7.11

PROPOSED KEY STRATEGIES – PROMOTION OF NURSES

Promotion opportunities for nurses should match the professional designations used and be accepted universally, especially for teaching and research cadres. It is recommended that: 



higher promotion in all cadres must be linked with the attainment of higher qualifications and/or training in all cases, where maximum degrees expected to be attained according to nationally available options. promotion in the service sub-cadre for nurses in BPS 18 and above should be linked with: 

the attainment of some higher management qualification or



in-service training

Diploma in Nursing Management to be made mandatory for promotion in the new service rules for BPS 18 and above.

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   

introducing a system of continuing education, whereby certificate level short courses are arranged for attaining each step promotion in the nursing service sub-cadre best performers must be provided incentives through faster career tracks approved educational/career pathway must be in place for teachers acquiring higher qualifications in education and in the clinical specialty they teach. posts of Asst Director Nursing in five divisions need to be reactivated and they should be made accountable for the performance of the division. 7.11.1 Proposed Service Structure

The nursing cadre is joined by those who posses formal nursing education through courses of RN, RM, or BScN and also by those who pass LHV Diploma or Diploma in Midwifery. Therefore, nurse cadres may be further subdivided into three sub-groups: 1.

Nursing staff with formal nursing education (N1)*

Nursing staff with LHV Diploma (N2)

Nursing staff with Diploma in Midwifery (N3)

7.11.2 Career Tracks

Three career tracks are proposed: 

A for those who have achieved highest qualifications of the field and have made a positive difference by their efforts



B for those who have achieved higher qualifications of the field and



C for those who have only attained minimum required qualifications for appointment.

7.11.3 Nomenclature

Separate nomenclature is proposed by virtue of the area of work: •

Nurses working in hospitals

•

Nurses working in the Ministry

•

Nurses working in academic institutions

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Table21: Proposed Designations for Nurses

Designation A B C D

Hospital

Academic Institute

Staff Nurse

Assistant Nursing Inspector

Junior Lecturer

Senior Staff Nurse

Associate Nursing Inspector

Lecturer

Asst. Manager Nursing

Nursing Inspector

Senior Lecturer

Manager Nursing

Assistant Director General (Nursing)

Asst. Director Nursing

Associate Director General (Nursing)

Deputy Director Nursing

Deputy Director General (Nursing)

Assistant Professor / Subject Specialist at CON Associate Professor / Assistant Director Nursing (Edu) Sr. Associate Professor / Deputy Dean

Director Nursing

Additional Director General (Nursing)

Ministry

Professor / Dean

Table 22: Graphical Representation of Service Continuum for Nurses

Years in Service 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25

BPS-16 A A A A A

BPS17(a)

BPS17(b)

BPS-18

BPS19(a)

BPS19(b)

BPS-20

B B B C C C C D D D E E E F F F F G G G

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Table 23:

Designation A

Minimum Qualification/Training for Various Sub-Grades

Hospital

Ministry

Academic Institute

RN, RM, DNM, DNE, BSN, or equivalent RN, RM, DNM, DNE, BSN, or equivalent CME 10 H

RN, RM, DNM, DNE, BSN, or equivalent

RN, RM, DNM, DNE, BSN, or equivalent RN, RM, DNM, DNE, BSN, or equivalent CME 10 H

CME 20 H

PG Degree

CME 30 H

PG Degree

CME 40 H

Doctorate / PG Degree

PG Degree

Doctorate / PG Degree

CME 10 H PG Student

Table24: Total Publication Requirement for Various Sub-Grades

Designation A B C D E F G

Hospital

Ministry

Academic Institute

x x x x x x 1

x x x 1 2 3 5

Source: Draft Career Structure for Health Professionals, Pakistan Medical Research Council, National Commission on Career Structure for Health Professionals, Feb 2008

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Lady Health Visitor 7.12

PROMOTION – CURRENT SITUATION IN PUNJAB

LHVs are working in BPS Scale 9. There is no career ladder and the profession is in status quo since its inception in 1958. Provincial General Inspector Health post is vacant since 1996. There are sanctioned posts of Divisional Asst Inspector Health, one in each District. Currently these posts are lying vacant. There is a need for reactivation

7.13

PROMOTION –ANALYSIS

Those LHVs in practice are keen to advance their career in the same field but due to the lack of any in-service training programmes or degree programmes, there is little that they can do. Some move on to nursing after doing four years General Nursing Diploma. Although the eligibility for both the LHV Diploma and General Nursing Diploma is the same, an LHV takes six years to become a nurse as no credits are offered for the two years of training that she had received at the PHNS. There is a need to provide refresher courses for those LHVs who have been away from work for more than two years. This will contribute towards addressing the shortage of LHVs. It is also essential to initiate a Bachelors Degree Programme for LHVs to provide opportunity for enhancing their knowledge.

7.14

PROPOSED STRATEGIES

Short Term 1. All posts for LHVs to be regularised 2. BPS Scale of LHV to be revised and brought up to a minimum of BPS 14 3. Refresher courses to be initiated for those LHVs who have been away from work for more than two years. 4. Establishment of LHV Association as a forum for advocacy and safeguarding their interest 5. Initiation of one year specialised diploma courses in subjects including but not restricted to Pediatrics, Family Planning, Vaccination, Hygiene, Nutrition, Viral Diseases, Midwifery, Public Health, Management, Communicable Diseases, Teaching Techniques, MNCH, Preventive Care and Administration. 6. Following appointments to be reactivated:   

Tehsil Inspectress of Health Centre at Tehsil Level District Inspectress of Health Centre at District Level Provincial Inspectress of Health Centre at Provincial Level 131

7. Career path linked to qualification, seniority and suitability to be put in place Medium Term 1. Career structure to be revised and the career ladder to take into account number of years in service and additional qualifications achieved. 2. Initiation of post LHV Bachelor Degree Programme in collaboration with international universities, till own faculty is prepared to take over academic appointments. Long Term 1. Initiation of post LHV Masters Degree Programme in collaboration with international universities

7.14.1 Proposed Service Structure

Table 25: Proposed Designations for LHVs Designation A B

Hospital LHV Senior LHV

Academic Institute LHV Senior LHV

Junior LHV Inspector

Junior Instructor

LHV Inspector

Instructor

Lecturer

Assistant LHV Superintendent LHV Superintendent

Senior LHV Superintendent

Principal

Senior Lecturer

Table 26: Minimum Qualification/Training for Various Sub-Grades

Designation A B C D E F G

Hospital LHV Diploma or equivalent LHV Diploma or equivalent CME 10 H CME 20 H Bachelors Bachelors

Academic Institute LHV Diploma or equivalent LHV Diploma or equivalent CME 20 H Bachelors Bachelors

Masters / Bachelors

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Table 27: Graphical Representation of Service Continuum for LHVs

Years in Service 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25

BPS-12 A A A A A

BPS14(a)

BPS14(b)

BPS-16

BPS17(a)

BPS17(b)

BPS-18

B B B C C C C D D D E E E F F F F G G G

Table 28: Total Publication Requirement for Various Sub-Grades

Designation A B C D E F G

Hospital x x x x x x 1

Academic Institute x x x x x 1 2

Source: Draft Career Structure for Health Professionals, Pakistan Medical Research Council, National Commission on Career Structure for Health Professionals, Feb 2008

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Midwives PROMOTION â&#x20AC;&#x201C; CURRENT SITUATION

7.15

Currently there is no promotion ladder for midwives in Punjab. Despite having 141 Schools of Midwifery, there is no College of Midwifery for the competent midwives to advance their careers.

7.16

PROPOSED SERVICE STRUCTURE

This group includes nursing staff that have completed Diploma in Midwifery at the time of induction into service. Separate nomenclature for seven sub-grades of nurses in this subgroup in BPS-based Health Professional Pay Scale for nurses with Diploma in Midwifery (HPPS-N3) system, by virtue of their area of working, is proposed as follows: a. Midwives working in hospitals b. Midwives working in academic institutes

Table 29: Proposed Designations for Midwifery

Designation A

Midwife

Academic Institute Midwife

Senior Midwife

Junior Midwife Inspector

Junior Instructor

Midwife Inspector Assistant Midwife Superintendent Midwife Superintendent Senior Midwife Superintendent

Instructor

E F G

Hospital

Lecturer Senior Lecturer Principal

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Table 30: Graphical Representation of Service Continuum for Midwifery

Years in Service 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25

BPS-11

BPS14(a)

BPS14(b)

BPS-16

BPS17(a)

BPS17(b)

BPS-18

A A A A A B B B C C C C D D D E E E F F F F G G G

Table 31: Minimum Qualification/Training for Various Sub-Grades

Designation A

C D E F

Hospital Diploma in Midwifery or equivalent Diploma in Midwifery or equivalent CME 10 H CME 20 H Bachelors Bachelors

Academic Institute Diploma in Midwifery or equivalent Diploma in Midwifery or equivalent CME 20 H Bachelors Bachelors Masters / Bachelors

Masters / Bachelors

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Table 32: Total Publication Requirement for Various Sub-Grades

Designation A B C D E F G

Hospital x x x x x x 1

Academic Institute x x x x x 1 2

Source: Draft Career Structure for Health Professionals, Pakistan Medical Research Council, National Commission on Career Structure for Health Professionals, Feb 2008

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Lady Health Workers 7.17

PROMOTION – CURRENT SITUATION

Currently there is no promotion protocol for LHWs.

7.18

ANALYSIS – PROMOTION

In the absence of a promotion policy there is little incentive or motivation for LHWs to work hard and develop a ‘career’ within this programme. The result is frustration, particularly for those who have potential and capacity to do more and inevitably they leave the programme. One option could be to support the LHWs with potential to take up a profession in the allied health services e.g. LHV, community midwife or move into nursing.

7.18.1 Mainstreaming the LHW Programme Currently there is some debate within the health sector and donor community about whether or not LHWs should be mainstreamed into the regular health service system thereby providing a service structure. Clearly there are pros and cons for this as indicated below:

THE PROS AND CONS OF MAINSTREAMING THE LHW PROGRAMME Positive Points: 

could bring standardisation across the programme



would provide LHWs with more job security and long term benefits



could provide a career structure with career growth opportunities for high performers



would allow space for LHWs and LHWSs to develop a union/affiliation to support them as a workforce; this could also lead to registration/accreditation processes in the longer term

Negative Points: 

may bring more HR problems for the health department which is already facing many such challenges



will be a significant HR financial burden on the health department



the spirit of volunteerism under which it was originally developed will be lost



flexibility of working hours, times and days will be lost which may restrict many LHWs who currently fit their work around family responsibilities 137



would be an additional administrative burden for an already over burdened health department

Paramedics 7.19

Promotion - Current Situation

As indicated in previous sections the comprehensive study into the service structure and rules and regulations of the paramedic cadres has recently been completed and recommendations made for considerable re-structuring. This includes re-structuring of the promotion protocols and BPS Grades for all cadres. It is recommended that the re-structuring plan be developed and rolled-out without delay to meet the requirements for the MSDS and the recommended HR strategies as outlined in this report with particular reference to recruitment and retention, performance management and promotion.

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Policy Triggers Section Eight

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8.1 POLICY TRIGGERS – OVERVIEW

Policy triggers generally refer to a set of circumstances that ‘trigger’ a particular action or next step to be invoked if a certain set of circumstances or situation arises. The idea is that an action or response could only be invoked if a pre-determined action, ‘policy response’ was already present for that particular trigger. Developing the policy trigger is the relative easy part; the weakness or challenge lies in developing and actioning the pre-determined response. An added factor is that there may be a considerable time lapse between agreeing a predetermined response and it being invoked. This may be further compounded by a change in the policy and or the political environment. Therefore while in essence a useful mechanism in reality a real challenge to achieve a positive outcome. These factors need to be borne in mind while developing policy triggers and determining the policy response to be invoked. The value and utilisation of policy/condition trigger mechanisms is therefore questionable.

8.2 KEY POLICY TRIGGERS FOR HEALTH HUMAN RESOURCES IN PUNJAB



Pressures of supply and demand – contributing to the imbalances within the workforce; creates HR shortages; affects quality of care



Lack of reliable HR data; implications for all HR functions e.g. planning, management and development - need to situate HR within the local, district, provincial and national context



Challenges in assessing shortages and gaps in health human resources; ineffective HR planning; gaps in data



Demographic trends influencing HHR requirements e.g. population growth, urban rural divide, disease prevalence shifts – BOD, increase of non-communicable disease trends



Levels of satisfaction of health care personnel – implications for retention and quality



Changes in roles and responsibilities of health staff to meet the MSDS – implications for supply and education of health staff



Human resource requirements to meet MDG targets; implications for HR planning and development and forecasting



Numbers of GPs, generalists and specialists – skewed ratios and imbalances; impacts on service delivery i.e. MNCH services;



LHWs programme, key workers for the achievement of MDGs and related MNCH care, are outside the mainstream health care system – operating like a vertical programme; has implications for ‘control’, planning and financial resource

140



Lack of GPs and specialists for achieving MNCH, PMDGP targets; lack of GPs also impacts on hospital walk-in services as first line screening is not done and very high numbers of patients present in emergency services when it is not required



Ineffective and non-transparent HR policies affecting staff satisfaction, performance, quality of care and organisational goals; high levels of absenteeism, increasing levels of migration/emigration, increasing migration into private sector



Increasing levels of migration of doctors and nurses creating further shortages and imbalances



Lack of effective leadership affecting organisational outcomes and staff performance



Weak CME/CPD protocols, quality and opportunities affecting quality of care, performance, retention, motivation; lack of opportunities for senior nurses and midwives



Market rates for salaries increases; cost of living increases; impacts on recruitment and retention



More collaborative team approach to working has implications for education and management of health personnel

 

Large number of staff hours lost to dual practice; policies currently in place ineffective and not applied



Nursing care focus issues – hospital/community/rural/urban has implications for nursing education



Working conditions – impact on recruitment and retention; quality and performance

POLICY TRIGGERS FOR YEAR 1 YEAR One

One

TRIGGERS/CONDITIONS Pressures of supply and demand for key cadres; shortfall of key staff to meet the PMDGP e.g. female doctors, nurses, LHVs Lack of HR data for planning and forecasting HR requirements; lack of HR planning to meet the requirements for the PMDGP and MSDS Low levels of satisfaction of health personnel; retention implications; quality of service issues Changes in roles and responsibilities of health staff to meet the PMDGP and MSDS Skewed ratio of health cadres; gender imbalance

POLICY ISSUES Increase the number of seats in training institutions; increase the number of sanctioned posts to absorb output.

Development of a HRMIS linked to the development of a comprehensive HR Department with qualified staff supported by HR policies and protocols

Implement in full the HSRP; review and update incentives annually; assess salary levels against market rates; review additional allowances annually Use of updated job descriptions as a policy issue; implement MSDS work plan with modifications to accommodate staffing levels in FLCFs; increase staffing levels in health facilities according to utilisation rates Remove all age restrictions for female staff; implement the paramedics restructuring plan 141

One

Poor working conditions; implications for retention, performance, quality of service

One

Ineffective and nontransparent HR policies affecting staff satisfaction, performance, quality of care and organisational goals

supported by amended policies; develop options for part-time and flexi-time for staff, particularly females; allow double shifts with overtime payments; pay for on-call hours for MNCH staff; provide child care support; provide married quarters/accommodation for families; enforce a 2 year bond system of intention to practice for all medical students; include PHC placements in medical training; develop a ‘return to work’ policy for female staff; develop a new service of career counselling for all potential health professionals – this would need to spread over a 2-year period Fully implement HSRP and related policies; continue to improve physical working environment – minimum standards established at a policy level and followed for each type of health care facility in terms of physical infrastructure including accommodation Develop and implement revised HR policies particularly for recruitment, performance management and promotion for all key cadres; this would be part of the HR Department – a HR policy guideline/manual would also need to be developed; this work would spread into year 2; e.g. annual performance review would become a policy for all staff; promotion policy would require promotion to be linked to performance and mandatory CME/CPD number of hours per year; doctors required to reregister annually with PMDC supported by specific requirements of hours of practice/research and CME

POLICY TRIGGERS FOR YEAR 2 YEAR Two

TRIGGERS/CONDITIONS Lack of GPs and specialists for MNCH

Two

Vacant posts in rural areas particularly for female staff;

POLICY ISSUES Vocational training opportunities for GPs to be mandatory; promote GP practice with incentives; recognition of DHQ/THQ hospitals as training placements for PG doctors; rotational posting to same especially for OBGY/anaesthetists mandatory; PHC mandatory part of medical and nursing curricula; mandatory postings to PHC facilities during training; In addition to those suggested for year one also develop a policy for recruiting locally and posting locally; provide support and incentives for students from rural areas in colleges; provide incentives to those colleges who offer electives in PHC for a limited number of students who will then take up rural postings for at least 2 years; 142

Two

Increasing levels of migration of doctors and nurses creating shortages and imbalances

In addition to those policies suggested for year one develop a policy for the management of migration; link to international protocols currently being proposed globally

Two

Lack of effective leadership affecting organisational outcomes

Two

Weak CME/CPD protocols, quality and opportunities affecting quality of care, performance, retention, motivation; lack of opportunities for senior nurses and midwives

Two

Market rates in association with salary increases; cost of living increases; impacts on recruitment and retention

Develop leadership development programmes which become mandatory for all senior staff in leadership roles; similarly senior management development programmes for all mid-level/senior managers; mandatory for promotion into such posts â&#x20AC;&#x201C; leadership policy; this would also spread into year 3 Policy alignment for all CME to be accredited and mandatory for re-registration, promotion, further PG studies; service rules to be updated accordingly. Nursing professionals also required to complete x number of hours CPD for promotion; more opportunities to be made available for nursing professionals PG studies with recognition and absorption planning Policy framework required for faculty strength i.e. number of student to teacher/demonstrator ratio minimum standard required. M&E policy required to ensure quality and compliance in all training institutions for all programmes There needs to be a policy to annually assess market rates, cost of living and minimum standards for salaries and remuneration packages; this would be linked to finance and budgeting cycles

POLICY TRIGGERS FOR YEAR 3

YEAR Three

Three

TRIGGERS/CONDITIONS LHWs programme, key workers for the achievement of MDGs and related MNCH care, are outside the mainstream health care system â&#x20AC;&#x201C; operating like a vertical programme Large number of staff hours lost to dual practice. Policies currently in place ineffective and not applied

POLICY ISSUES Mainstream LHWs into the health care system and enhance the skills, roles and responsibilities with supportive service rules and policies

Re-align the policies to effectively regulate dual practice; policy development for the registration and regulation of dual practice

143

POLICY TRIGGERS FOR YEAR 4 YEAR

Four

TRIGGERS/CONDITIONS Changing demographic trends influencing HHR requirements e.g. population growth, urban rural divide, disease prevalence shifts – BOD, increase of noncommunicable disease trends

Nursing care focus issues – hospital/community/rural/urban has implications for nursing education and roles and responsibilities; links to demographic trends and shifts i.e. increase in non-communicable diseases more palliative home care required and less hospital based care More collaborative team approach to working to reflect demographic trends has implications for education and management of health personnel

POLICY ISSUES This requires a long term policy for review and re-assessment of staffing needs and skill and cadre mix and balance. This would form a key responsibility of the HR Department, HR planning team who would be mandated to develop 5-year rolling plans for HR requirements in close consultation and coordination with all districts. Adjustments would have to be made according to demographic changes and trends Policy shift required to promote community based nursing care; home care services at the door-step; implications for nursing education and registration in different categories.

Hospital policies to reflect new nursing care protocols for example – team based patient care; similarly for FLCFs, team based care systems may require supportive policies for HR management; protocols with policies to be developed to support team based working, incentives, rewards, performance

144

International Models and Perspectives Section Nine

145

9.1 INTERNATIONAL PERSPECTIVE Pakistan is not the only country facing challenges in the health human resource sector. In many parts of the world, both north and south, developed and less developed governments are increasingly facing issues relating to the recruitment and retention of health care professionals with the right skills mix to provide the level of health care required to meet the health care needs of their populations. Of most concern in Pakistan is the on-going challenge to provide health care to rural populations, lower income groups and more especially to women and children who are often the most vulnerable when health care services are scarce and inadequate. Health care provider projections from many of the developed countries, including USA, UK, Canada and Australia and developing countries, including Bangladesh, Malawi and Tanzania increasingly indicate a growing shortfall in the number of full time nurses, general practitioners and other allied health care workers particularly in remote rural areas.1;2;3;4 There is a great need to ensure that there are not only enough health care staff to meet the health care needs of any given population but also to ensure that the right type of staff are available in the right place with suitable and adequate skills and resources to meet the health care needs of the population. In considering this, socio-economic, demographic and burden of disease elements together with political, geographical and cultural issues also influence the ability of the health service of any country to deliver health services.

9.2 CONTEXT Globally over the past five years or more many countries have witnessed a growing crisis in health human resources; from the USA to Australia, Africa to the United Kingdom and many poorer countries in between; the shortage, skill mix and imbalances in health care providers is posing challenges for the provision of sustainable, quality health care. In a recent analysis of the global health workforce undertaken by the Joint Learning Initiative - a consortium of more than 100 health leaders 5 it was proposed that strengthening the health human resource is the most critical issue for many countries in the provision of health care services. Many of the HR challenges are common in many countries; mal-distribution of staff with an urban bias, negative work environments, migration, weak knowledge base and poor human resource frameworks, especially in the poorest countries. It is pertinent here to look at some international practices that are being tried and adopted to address the growing global challenges of human resources for health in a mix of socio-economically diverse countries yet each facing HR challenges. 1

Australian Primary Health Care Research Institute 2007 Bangladesh Ministry of Health 2001 3 Ministry of Health, Malawi, 2006 4 Joint Learning Initiative, 2004 2

Lancet, 2004 V.364:1984-90

146

In this section five countries will be looked at for a variety of different human resource strategies and models that may supplement, offer alternatives or be likened to those being recommended in this document for the health department of Punjab.

Table 33 Summary of Health Indicators for the Selected Countries

COUNTRY

IMR

Bangladesh Malawi Australia

57 71 4.7

UNDER-5 MORTALITY RATE 82 111 13

Canada Tanzania

5 73

6 116

MMR 300 1,100 8.7 45.9 in remote rural areas

7 950

For comparison Pakistan

276

9.3 BANGLADESH

Rural Bangladesh is not unlike rural Pakistan in many aspects and the provision of rural health care faces many of the same challenges as that of Pakistan with a similar burden of disease pattern. Diarrhoeal diseases and Acute Respiratory Tract Infections are the primary causes of under-five mortality and non-communicable diseases such as cancer, diabetes and cardiovascular diseases are increasingly the leading causes of morbidity and mortality. Health Indicators Having an estimated population of over 145 million and a population growth rate of 1.51 percent in 2000 with a declining trend from over 2 percent in 19916 Bangladesh has made significant progress in health care provision, particularly in MNCH and reproductive health. Over recent years health and other social sector indicators have shown an encouraging trend of improvement including adult literacy rates of over 78 percent for males and 63 percent for females. IMR has declined from an estimated 92 in 1991 to 57 in 1998 and MMR from 470 to 300 in the same timeframe7.

Health Human Resources 6 7

Bangladesh Demographic and Health Survey 2001 Bangladesh Ministry of Health 2001

147

Currently however, rural Bangladesh is facing a health care crisis; public sector facilities are facing acute shortages of doctors, nurses and paramedical staff coupled with low quality facilities. As a result for most people in the community the first point of contact for health care is the traditional healers. Additionally there is a huge disparity between the number of health care workers in urban and rural areas; an estimated 85 percent of the population reside in rural areas. There are large numbers of health professional vacancies in rural areas; an estimated 18,000 are currently vacant, including 5,500 doctors, out of a total of 90,000 health care personnel positions. Bangladesh has an estimated 48,000 registered doctors to serve a population of 145 million8. Similarly a significant number of public sector doctors spend more of their time in private practice than public service provision9. Health System The national health policy gives priority to accessibility and equity in health care with a particular focus on rural, primary health care. Primary health care is focused around Upazilla Health Complexes (UHC), basically a health care hub at sub-district level. These UHCs provide both outdoor and indoor patient care having an average of 30 beds each; some as many as 50 beds. Daily utilisation rates vary widely. Additionally there are smaller facilities, Union Health and Family Welfare Centres with one doctor in charge. Bangladesh health services are hugely skewed towards the urban areas where an estimated one third of the available health personnel are employed and yet less than 15 percent of the population lives. It is estimated that most rural health facilities are grossly under-utilised largely due to high levels of staff absenteeism; some estimates quote 74 percent in smaller rural facilities and 40 percent in larger health units10; poor physical infrastructure, lack of basic amenities, drugs and equipment. According to a civil society network that monitors the health care situation, Bangladesh Health Watch, estimates that over 80 percent of the population turn to non-state providers for health care, including traditional birth attendants, local healers and NGOs. This is highly reminiscent of the situation in Punjab. The Bangladesh Model In 1997 the government of Bangladesh developed a new health policy using a participatory approach for the first time. A new approach in the health sector was initiated aimed at ‘outputs’ rather than ‘inputs’. There is also an initiative to merge and integrate the health and family planning departments for improved management and a greater degree of decentralisation. Priority is given to accessibility and equity in health care provision particularly in rural areas and for MNCH. Bangladesh has managed to develop a nationwide network of health services delivering different levels of health care. New Initiatives

Ministry of Health, Bangladesh, May 2009 Irin Report, 2009; World Bank Economic Review 2003 10 World Bank Report, 9

148

Current initiatives include the development of an essential services package to be delivered from a static service point rather than household or community visits by community health workers11. This will require a major reorganisation of the service structure and is expected to reduce costs, increase efficiency and meet public demand. Privatisation of health care at tertiary level is also being considered on a selective basis. In a response to the loss of confidence in the public sector health care, especially in rural areas, in 2009 the health department launched nationwide awareness campaigns including a health care week launched to coincide with World Health Day. Production of Health Human Resources Bangladesh has a wide range of government and non-government institutions involved in the production and development of the health care workforce. The public sector includes a medical university, five post-graduate medical institutes, 13 medical colleges, one dental college, one nursing college, thirty-eight nursing institutes, two institutes for health technology and eight Medical Assistants training schools. Additionally the non-government sector runs nineteen medical colleges and a variety of other health training institutions. Health Human Resources Strategies A number of reviews of health sector performance indicated a need to improve health human resource management and development functions if Bangladesh is to achieve the goal of quality health care for all. WHO is supporting human resources development activities in Bangladesh through a number of initiatives; these include:



Development of methods, guidelines and tools for planning, managing, and improving the performance of the health workforce



Production of health care staff with appropriate skills mix, attitude and abilities necessary to deliver health care



Provision of support by the Human Resources for Health Programme to the Bangladesh College of Physicians and Surgeons, the Medical University, National Institute of Preventive and Social Medicine, medical colleges and paramedical institutes to enhance the managerial and technical capacity



Improving standards of fellowship examinations in BCPS



Enhancing the teaching resource of medical colleges and other institutions



Updating and facilitating implementation of medical and paramedical curricula



Technical capacity building of teaching staff of medical and public health institutes through external training and study tours



Institutionalising Quality Assurance in medical and paramedical institutes.

Ministry of Health, Bangladesh 2009

149



Establishing continuing medical education programmes for teachers of medical colleges



Generating evidence for health workforce planning and best teaching practices



Generating evidence about best public health practices

HUMAN RESOURCE KEY STRATEGIES IN BANGLADESH          

Implementation of a performance management protocol Strengthening education and training at all levels for all cadres including skills development Management development programmes Strengthening continuing medical education Building faculty strength and capacity Strengthening medical education Curricula revision and updating Strengthening paramedics education and services Development of a teaching cadre Promoting a culture of research and evidence based practice

150

9.4 MALAWI

Although Malawi is a much smaller country than Pakistan with an estimated population of 14 million, like many countries in Africa Malawi is facing unprecedented challenges in the provision of health care and most particularly in health human resources not unlike those of other developing countries and Pakistan. Malawi is investing considerably in the planning, management and development of health human resources. After years of health planning without explicitly defined health service priorities, the Government of Malawi has recently formulated a plan to provide an essential health package that supports its targets of achieving the Millennium Development Goals.

Health Indicators The key issues of high child mortality and morbidity, under-five mortality stands at 111 per 1000 live births the main causes being diarrhoeal diseases, ARI and measles, IMR at 71 and high maternal mortality and morbidity with MMR at an estimated 1,100 per 100,00012 are compounded by high HIV sero-prevalence and deaths due to HIV and AIDS related illnesses and limited access to effective health care, particularly in rural and hard to reach areas.

Health Human Resources This is further affected by shortages, limited capacity and mal-distribution of trained health personnel; 0.37 nurses per 1000 population and 0.05 doctors per 1000 population 13 ; shortages of essential drugs, medical supplies and equipment; and inadequate resource availability coupled with inefficient and inequitable distribution. A major reason for Malawiâ&#x20AC;&#x2122;s weak health sector performance is due to the crisis in the health sector workforce. Key issues include acute shortages of health staff, most especially nurses; weak human resource systems and policies and unmanaged growth of NGOs in the health sector. The health human resource crisis is evident from an estimated vacancy rate of 75 percent. The vacancy rates are particularly high for skills that are most needed; specialist doctors, 82 percent, nursing officers 77 percent and nursing sisters 87 percent, lower-level nurses 41 percent, environmental and health education officers around 70 to 80 percent, pharmacists 68 percent and lab technicians 40 percent14. The health workforce challenges in Malawi are daunting requiring proactive, rapid solutions. Key interventions and models are cited below.

The Malawi Model Increasing the Production of New Health Workers This is mostly being approached through an expanded training programme, the Emergency Training Programme; this is intended to get new entrants into the health workforce and was initiated in 2001. The programme includes nurses, paramedics and auxiliary nurses and set 12

UNICEF, 2007 Joint Learning Initiative, 2004 14 Malawi Ministry of Health, 2009 13

151

a target of over 15,000 health workers to be produced by the end of the planned period and 2,000 existing staff to receive upgrading courses. The role of professional bodies as regulators also had to be clarified. A new diploma course for training registered nurses was initiated during 2004 with the first batch available in 2008. Additionally the number of Health Service Assistants, later known as Auxiliary Nurses was doubled and, combined with over 3,000 existing Auxiliary Nurses significantly increased the number of health providers at this level. Additionally the in-service training for health workers was fully integrated and coordinated by gradually combining selected courses with a view to developing a more comprehensive programme and system including distance learning. Additional initiatives taken included: 

Formal bonding arrangements for persons trained under the government subsidised programmes



Reduction of government subsidies for training and the use of distance learning



Public private partnerships for education of health workers



Mandatory government service, often in rural areas for at least one year



Management of international migration through such instruments as codes of international practice and re-entry mechanisms

Attracting Health Workers Back into the Health System The immediate initiative for this was a concerted, transparent yet rapid recruitment campaign to fill vacancies for which protocols were developed. Additionally outsourcing to a recruitment agency and attractive packages were also part of the recruitment drive to attract trained personnel back into the health system. Performance based contracts for rural postings with attractive rates of pay; upgraded salaries and benefits packages; clear career structures developed; improved gender management and better management of dual practice were also options for attracting and retaining health personnel. Strengthening HR Systems and Functions The existing HR systems and functions were not sufficient or comprehensive enough to cope with the health HR requirements. Additionally the existing mechanisms were cumbersome and bureaucratic and HR data grossly incomplete thereby failing to provide timely information for HR planning. A comprehensive review of the whole HR function was undertaken with the aim of developing a fully effective, efficient HR system to include all standard HR functions including the development of an effective performance management tool and policies for recruitment, career development and promotion and the development and implementation of a longer term HR strategy including human resource development plans.

152

The Role of NGOs The role of NGOs was re-examined in terms of producers of health staff as opposed to simply being users of health professionals. A considerable number of health care professionals, including lab technicians, nurses, midwives and pharmacists are working in the NGO sector in Malawi.15 The management of public sector staff being enticed into the NGO sector needed improvements; NGOs do not generally produce their own health professionals, rather they rely on those in government service or those who may have left. NGOs also offer better salaries and remuneration packages creating competition in the labour market. The government explored options for working closer with the NGO sector to develop a standard of good NGO practice in HR recruitment, deployment and use. This included making explicit the impact of the NGO projects on the current pool of trained health professionals. Some options were: 

Encouraging the NGOs to train their own workers



NGOs required to reimburse the cost of training of the public sector staff working with them



Negotiation with NGOs donors to allocate a proportion of the budget for the preservice training of health workers specifically to meet the NGOs’ HR requirements



Appeal to donors to extend the length of NGO grants to enable them to address longer-term HR issues with specific deliverables on human resource development.

Retaining Health Workers The government has introduced a number of innovations designed to retain health workers in the public sector. These include: (a) senior-level MOH performance contracts; staff are employed on a 3-year fixed-term contract renewable on achievement of a satisfactory level of performance with substantially higher levels of remuneration; if the performance is not satisfactory the contract is not renewed (b) sessional locums as a stop-gap measure in hospitals; hospitals use locum arrangements on a sessional basis, either using their own staff after they have completed their weekly allocated hours, or hiring trained staff from the outside to address current staffing problems. This is largely financed from fee revenues generated by the hospital. One district is creatively using allowances to entice health workers to provide temporary cover to currently un-staffed health centres. (c) various innovative HR retention schemes; these include upgrading salaries and benefits; improving working conditions, development of a career structure for all cadres and improved gender management, including recruiting more males into nursing and supporting this with the provision of male hostels at training institutions.

Hornby and Oczan, 2003

153

d) improved management of dual practice as a means of retaining staff on salaries that are lower than the market rate. This serves the interests of both the staff and the government; the staff gains from public sector employment, training, job security, status and in some cases access to patients who might be diverted to their private practice, while the employer retains staff, albeit usually on a less than full-time basis16.

KEY HUMAN RESOURCE STRATEGIES IN MALAWI        

Increasing production of health staff – expanded training programmes Development and implementation of retention mechanisms Mechanisms to attract staff back into the public health system Strengthening training and development of new opportunities Development and further strengthening of the HR system and functions including performance management Working with NGOs in more innovative ways Improved management of dual practice Improved gender management – male nurse training

Lerberge 2000

154

9.5 AUSTRALIA

Australia has a population of approximately 18 million living largely in coastal cities and towns; one third of the population lives in rural areas. Due to the extreme remoteness of some areas in Australia, including the vast inland deserts the areas are graded as ‘rural major’ and ‘remote major’ and ‘rural other’ and ‘remote other’17. Provision of health care in these areas is extremely challenging and access to health care by rural indigenous communities is very poor. Australia was taken as an interesting model as although in many respects a fully developed country it too is facing a health human resource crisis for the delivery of health care in very remote rural areas, particularly a shortage of GPs, not unlike that of Pakistan. There has been much speculation, anecdotal evidence and many personal suggestions and experiences made as to the cause of this shift in popularity of general, rural practice as a career18 in Australia. The impact on the provision of rural health care is a growing concern.

Health Indicators The overall health indicators for Australia are very good with IMR at 4.7; MMR at 8.7 and under five mortality at 13.19.20 The indicators for remote rural and indigenous communities are significantly higher with MMR at 45.9 and IMR up to 2.6 times higher.21 Similarly the under-five mortality rates are generally considerably higher in the indigenous communities with ARI and measles still affecting many young children.

Health Human Resources Australia has ten medical schools and currently almost 60,000 doctors half of whom are specialists and half are GPs; only seven percent practice in remote and rural areas. The number of doctors per 100,000 head of population in urban areas is 312 while in rural areas it is 141.22 Moreover it is not only doctors who are unwilling to take up posts in such rural areas and within the community but also other healthcare professionals including nurses. Health professionals are greatly needed in rural areas of Australia and in an effort to understand the reasons and provide solutions to these challenges, particularly of reluctance to practice in rural areas, factors affecting the recruitment and retention, career choices and practice location choices of medical students and junior doctors have been explored. Additionally as in Pakistan the feminisation of the medical workforce has also been a factor in human resource planning and deployment. Between 1991 and 2003 the percentage of 17

Australian Government Publishing Services, 1994 Australian Health Care Research Institute, 2007 19 Australian Government, 2006 20 A.I.H.W. 2009 21 A.I.H.W. 2005; 2009 22 Australian Government, 2006 18

155

women choosing a medical career rose from 19.3 percent to 35.2 percent, many of whom choose to work part-time only23 thereby reducing the actual number of full-time equivalents practising. Health System Most patients seeking primary health care are seen by a GP or family practitioner as the first line of contact with the health system; they are referred as necessary for specialist care. There is a dual system of public and private health care provision. Hospitals provide both public and private care; for non hospital health care doctors may bill the patients privately or charge the government directly. Approximately 30 percent of GP services are billed privately. Hospital services may be billed in the same way but state governments are responsible for public hospitals24. The focus is on quality, access and equity. The Australian Model In order to try to understand the problem of human resource provision in remote and rural areas and thereby mitigate it the Australian Health Care Research Institute investigated how the following factors may impinge on the career choice of health professionals, primarily doctors: 

Changes in medical school curricula and clinical placements



Increases in the numbers of medical students



Rural clinical school and rural practice placements



Exposure to general practice at the pre-vocational level (postgraduate years 1 and 2)



The evolution of inter-professional/multidisciplinary education and practice

Key factors and actions found to affect choice on rural medical careers included25: 

School programmes and outreach programmes for young people; career counselling



Selection that considered the nature of potential students; positive discrimination for those students having a history of community service and background



Career choice at entry to medical school; selection of those stating a preference for rural practice and general practice



Selection of more students from a rural background



Academic ability; preference to broad background, less interest in research



Financial incentives; bonded places and grants to tie students to specific careers

Charles J, Britt H, Valenti L. 1991-2003. Med J. Aus. 2004; 181: 85-90. Australian National Health Strategy 1991 25 Australian Health Care Research Institute, 2007 24

156



Clinical attachments, GP and rural; earlier and longer placements with attention to hands-on learning and GP electives



Increased rural attachments during training



Positive portrayal of rural postings; prestige to rural workers; positive role models



Enhanced role of GPs and rural health staff in teaching and mentoring



Flexible post graduate training opportunities for GPs and rural doctors and nurses



Compulsory rural term in post graduate training for doctors and nurses



GP remuneration packages in line with other specialists

Human Resource Strategies Policies to increase Recruitment in Rural Areas 

In the student selection process for medical and health professionals consideration is given to providing additional incentives to those medical and nursing schools that proactively promote entrance to rural and GP practice following qualification



More financial support given to students of all health professions entering from rural backgrounds as students from rural backgrounds are more likely to practise in rural areas



Additional targeted funds made available at the time of re-accreditation processes to medical and health professional training institutions providing effective career counselling on career choices including rural practice



Medical schools are encouraged to increase the number of teachers and facilitators from rural practice bringing positive role models into medical and health professional training schools



Additional funding for new community clinical schools in each medical college to provide an increased quantity and quality of exposure to rural and GP work



Development of a national organisation within the College of Family Physicians to focus on the development of education for rural practice. This includes the development of curricula for rural training streams and third year advanced skills programmes



Post graduate training GPs are provided additional resources to encourage them to host junior doctors through post graduate general practice placements



A general practice placement mandatory for all junior doctors in PG year one or two

157

KEY HUMAN RESOURCE STRATEGIES IN AUSTRALIA        

Incentives to medical schools promoting rural and GP practice Financial support for students from rural backgrounds Targeted funds made available at the time of re-accreditation for institutions providing career counselling and promotion of rural practice Increase in the number of teachers from rural backgrounds Additional funding for clinical community schools Development of a national organisation to focus on the development of education for rural practice Additional resources to GP trainers to host PG junior doctors in rural practice Mandatory GP practice for all PG doctors in training

158

9.6 CANADA

As in Australia, Canada is also facing similar problems in terms of health care provision in remote rural areas and finding better ways to educate, recruit and retain rural health care workers has taken on a priority. Additionally Canada is facing a growing shortage of health care providers and providers with the appropriate skills for the changing burden of disease. Canada is the second largest country in the world in terms of land mass yet has a population of only 27 million the greatest majority of whom live within less than one hundred miles of the southern border with the United States26. Equally Canada has very remote rural areas in the far north and one third of the population reside in rural areas. Health Indicators Canada has some of the best health indicators in the world; IMR stands at just five per 1,000 live births; under five mortality at six and MMR at seven per 100,000 live births.27 With an ageing population the burden of disease has shifted to non-communicable diseases and life care for elderly persons. Health Human Resources Having approximately 50, 000 doctors, from 16 medical schools, with a similar number of specialists and GPs, only 11 percent practice in rural areas28. With very similar problems in terms of recruiting and retaining health professionals in rural areas as Pakistan and Australia similar studies and initiatives have been undertaken to determine the causes and solutions. Similarly findings indicate that those students from rural areas and those who have positive clinical experiences at both under-graduate and post graduate levels are more likely to practice in rural areas. Most provinces and territories in Canada have moved the academic entry requirement for registered nurses to the baccalaureate level; several provinces and territories have also increased seats in medical schools aimed towards those students wishing to become family physicians, GPs. Nurses are highly trained, well respected and provide a very high standard of care. Additionally allied health care providers, such as dieticians, technicians and pharmacists are highly skilled and work as part of the overall health team approach to health care provision in Canada. Health System The Canadian health care system is publicly funded and consists of five general groups: the provincial and territorial governments, the federal government, physicians, nurses and allied health care professionals.

The Canada Year Book, 2004 UNICEF 2007 28 Canadian Medical Assoc.1998 27

159

The federal government is responsible for setting national health care standards and ensuring that standards are enforced by legislative acts such as the Canada Health Act. Provincial and territorial governments are responsible for managing and delivering health services as well as planning, financing, and evaluating hospital care provision and health care services not too unlike the system in Pakistan. The Canadian Health Authority is responsible for ensuring that all Canadian citizens have access to health care regardless of their ability to pay. This is in stark difference to the situation in the United States. Private practicing doctors are not generally employed by the government; rather they are self-employed and work in a private practice. They provide publicly-funded health care to Canadian citizens through negotiated ‘fees for services’ with the provincial governments on a reimbursable basis. The Canadian Model The Canadian model of health care is all inclusive, providing services for all citizens wherever they live or whatever their economic status including First Nation communities and remote, rural communities. Increasingly there is a move towards a multidisciplinary team approach which is patient-centred and where all concerned are involved in decision making including the patient. Human Resource Strategies 

Career promotion days in high schools supported by promotion materials distributed in rural areas to enhance recruitment into the health professions



Opportunities for learning in a rural setting; rural placement during medical and nurse training



Opportunities for senior school students to spend some time during school holidays in medical schools or other health training institutions



Support for students from rural backgrounds and the promotion of medical education in rural areas



Positive attitudes fostered in medical schools, the government and the public at large towards the recognition of rural practice as a career



Post graduate opportunities to spend time in rural practice



Financial support for rural doctors to undertake CME programmes



Increased seats in medical schools aimed at students planning to become GPs



Strengthening recruitment and retention protocols



Increased educational level of nurses at entry and post graduate opportunities

160

KEY HUMAN RESOURCE STRATEGIES IN CANADA        

Career promotion in schools Rural placements Support for students from rural areas Promotion of rural practice as a viable career Continuing medical education opportunities for staff in rural posts Recruitment and retention protocols enhanced Increased education level for nurses Increased seats in medical schools for those intending to undertake GP practice

Both Australia and Canada recognise that more still needs to be done to recruit and retain health professionals particularly in rural areas. While advances and innovations in medical education is contributing significantly to increasing the number of rural doctors and other health professionals working in rural areas this alone will not be sufficient to resolve the growing problem. There is a need to recognise rural practice as a distinct discipline with remuneration and benefits packages to reflect that. Pakistan would do well to explore some of these options too.

161

9.7 TANZANIA

Tanzania is a relatively small country in comparison with Pakistan with an estimated population of just over 38 million. As with many countries in Africa the spread of HIV and AIDS has had a devastating effect on the health systems in terms of burden of disease, patient care and loss of health staff in the system. Health Indicators In the past Tanzania had seen some improvements in health indicators however, with the growing HIV and AIDS crisis this has had significant impact on the health care system as with many other countries in Africa in terms of burden of disease and loss of staff. The infant mortality ratio is 73 per 1000 live births; under-five mortality at 116 and the maternal mortality ratio 950 per 100,000 per live births29. The main causes of under-five mortality are similar to those of Pakistan, diarrhoeal diseases, measles, ARI and malaria30 in addition to HIV and AIDs and related illnesses. Health Human Resources As with many other countries in Africa and globally Tanzania is facing a number of health human resource challenges in recent years not least of which is a shortfall in health personnel. There are 822 registered physicians, 0.02 per 1000 population which is probably the lowest in the world compared for example to Malawi at 0.05 and UK at 1.66; 13,292 nurses, 0.37 per 1000 population compared to Malawi 0.26 and UK at 5.4 and 25 hospital beds per 10,000 population31 which is low by both international standards and relative to Tanzania staffing norms. The health human resource crisis is witnessed by a shortage of personnel, geographical imbalances in the availability of health workers, weak productivity and performance management at health facilities. The following are a summary of the key challenges for the delivery of quality, effective health service in Tanzania32: 

The number of skilled health workers per capita is low and declining



The number of skilled health workers in rural areas is disproportionally low leading to inequitable access to health services.



There is a high proportion of unskilled, or very low skilled, health workers



The productivity and performance of health workers are both inadequate

The reasons for these problems according to the 2006 CMI report are various and include: low rates of recruitment imposed by structural adjustment programmes, changing and increasing burden of disease, high attrition rates, HR management issues including

UNICEF, 2007 WHO Statistics, 2006 31 Joint Learning Initiative, 2004 32 CMI Report, Human Resources for Health, Tanzania, 2006 30

162

performance and poor working conditions which in themselves further contribute to staff dissatisfaction and de-motivation. Health System The distribution of health facilities in Tanzania has a heavy rural emphasis as more than 70 percent of the population live in rural areas. The lowest level of care is provided in Village Health Posts, largely basic preventative services provided by village health workers; the next level is that of Dispensaries followed by Health Centres with referrals to District Hospitals and Regional Hospitals. Access to health care is frequently compromised by poor facilities and geographical location. The Tanzanian Model In 1994 the Ministry of Health undertook a review of health sector performance with the intention of raising strategies to improve the quality of health services and increase equity in health accessibility and utilisation. The key dimensions identified for reform included management, decentralization, financial reforms, such as enhancement of user-charges in government hospitals, introduction of health insurance and community health funds and dual practice reforms such as encouragement of the private sector to complement public health services. Organisational reforms such as integration of vertical health programmes into the general health services were also included. New Initiatives A health human resource working group involving government ministries and donors was appointed in 2004 in recognition of the need to address the growing health HR crisis. In 2005 the momentum to resolve the HR crisis gathered pace when the restriction on recruitment of clinical cadres was lifted. Human Resource Strategies Subsequent human resource strategies have included: 

Reinstatement of central recruitment for clinical cadres to speed up recruitment



Increase in the overall rate of recruitment



Strengthening of the health Human Resource Department



Development of a new HR policy document to form the basis of a new HR strategy



Incentives for remote and hard areas

Other recommendations have more recently included: 

Increase in training output – 3-5 year lead time



Increase in numbers through increased recruitment and improved retention rates – reduce attrition



Recruitment of in-active health workers 163



Utilise existing staff more effectively



Upgrading skill levels



Improve and better manage performance



Improve overall working conditions to attract staff and increase motivation



Consideration of significant salary increases



National recognition of HR crisis at the highest level



Build the knowledge base on HR including costs and policy options through targeted research and data collection

The health HR challenge of expanding priority interventions in Tanzania particularly in relation to the MDGs targets for 2015 remains daunting. The human resource requirements are still huge and heavily affected by the HIV and AIDS pandemic.

KEY HUMAN RESOURCE STRATEGIES IN TANZANIA         

Increased recruitment Strengthening of the HR Department supported by a new HR policy Incentives for rural postings Increased training output More emphasis on retention mechanisms Skills upgrades Targeted research to build the knowledge base Improved working conditions Strengthened performance management

164

9.8 SUMMARY

Clearly from the evidence given in this section and the models cited there is a lot that Pakistan and Punjab in particular may learn and replicate within the context of Punjab. No one model demonstrates and encompasses all best practice in the complex and diverse arena of human resources for health; rather a ‘pick and mix’ approach is suggested to meet the unique requirements of the Punjab health sector. Many of the initiatives being tried and implemented in these models have already been recommended in this study for the health department in Punjab. Table ?? below summarises the major strategies extrapolated from the five models explored here that could best be applied in the context of the Punjab health system to further strengthen the human resource strategies, functions and policies.

9.9 KEY STRATEGIES RECOMMENDED FOR CONSIDERATION IN PUNJAB

           

     

Develop and functionalise a comprehensive dedicated HR department Develop and implement an effective performance management protocol Strengthen education and training at all levels for all cadres including skills development Institutionalisation of management development programmes for mid and senior level managers Strengthen and rationalise continuing medical education with due accreditation Build faculty strength and capacity Strengthen medical education through curricula revision and regular review and updating Strengthen paramedics education and service structure (already being initiated) Develop a dedicated teaching cadre with relevant teaching and learning qualifications Promote a culture of research and evidence based practice Increase production of key health staff; nurses, midwives and specialists Strengthen retention mechanisms by improving the working environment supported by clear, efficient, transparent human resource policies and procedures universally applied Attract staff back into the public health system, especially females with a more conducive work environment including part-time/flexi-time hours Work with NGOs in more innovative ways Improve management of dual practice Improve gender management – increase male nurse training Actively promote rural practice through incentives, placements and awareness raising Provide financial support for students from rural backgrounds 165

    

Reassess the issue of GP training and further develop and promote GP training Make career counselling mandatory for all potential health personnel Develop a provincial ‘organisation’ to focus on the development of education for rural practice Mandatory GP practice for all PG doctors in training Increase seats in those medical colleges promoting and supporting students to undertake GP and/or rural practice

166

Emerging Issues Section Ten

167

In the light of the extensive work undertaken and insight gained during this assignment this study has highlighted several emerging issues that would require further study; some are linked to the recommendations also cited in this report others have emerged during the course of the information gathering, analysis and review processes and are recommended for further study. 1. A study of the private and informal sector to assess options for regulation and accreditation, training requirements and monitoring and accountability mechanisms. It is envisaged that this would require a minimum input of six months and would include both national and international specialists. Study Area: private and informal sectors in health Gap Identified: lack of accountability, regulation and accreditation of these sectors Key Objective: to develop regulatory and accreditation mechanisms for these sectors

2. Further assessment in respect of female medical studentâ&#x20AC;&#x2122;s intention to practice would be of benefit for the development of strategies to mitigate the large number of newly qualified female medical doctors who do not practice. It is understood that some work on this is being undertaken by AIMC and the Lahore Chamber of Commerce; these would be good starting points for further assessment if still required. It is envisaged that this could be undertaken with a national specialist or post graduate student. Study Area: female medical student attrition rates Gap Identified: high level of attrition of female medical graduates; limited knowledge of the reasons to be able to develop mitigating mechanisms Key Objective: to develop mitigating mechanisms and reduce attrition rates of female medical graduates

3. Dual practice of health staff particularly doctors and nurses is highly significant within the health sector and a large number of public service person hours are lost to private practice. A study to further assess and review the situation and explore options for regulation or other alternatives would be highly beneficial. Study Area: public private practice of health staff, most especially doctors and nurses Gap Identified: lack of detail as to the extent of dual practice of these key cadres of health workers thereby making it very difficult to find effective solutions, regulatory mechanisms and compensatory packages Key Objective: to develop regulatory and/or compensatory mechanisms to monitor and regulate this practice

168

4. As indicated in the recommendations, as part of the process to establish a comprehensive human resource department within the health sector it is important that an audit of the current human resource function is first undertaken. This would be expected to set benchmarks and scoping for the strategic development of the Human Resource Department. This would require substantial input working closely with the health department from both national and international specialists for a minimum period of six person months. Study Area: audit and scoping exercise for the development of a comprehensive human resource department within the health system Gap Identified: lack of a comprehensive HR department within the health system Key Objective: to develop the basis for the development of a comprehensive HR department within the health sector

5. Career counselling has been highlighted as an important strategy to support recruitment and retention. As this is a new area of work in Punjab it would benefit substantially from a study to explore the most appropriate options for initiating and implementing such a new area of work. The support of an international specialist with the relevant experience in career counselling would be important for this to be truly effective. Study Area: development of a career counselling service; scoping exercise to be followed by development Gap Identified: the need to offer career counselling for students and young people, and their parents, interested in taking up a career within the health sector Key Objective: to develop and provide a career counselling service for young people considering a career in the health sector

6. A vital area of work that is required as indicated in the recommendations is that of the development of a leadership programme for senior managers. This would need to be custom made and developed together with the health department senior team. An international specialist in human resource and/or leadership development would be required to undertake this area of work with the support of a local company or specialist. As the initial work would need assessment and scoping of the need and type of programme required a minimum of four months would be required. Study Area: Development of leadership development programmes Gap Identified: Absence of leadership development within the health department Key Objective: To develop a leadership programme for senior leaders/managers within the health department based on agreed key leadership behaviours; to develop a SMP (senior management programme) for senior managers within the health department; a scoping exercise would be required first.

169

7. In order to be able to plan and forecast human resource requirements accurately a reliable baseline is required. This is already being recommended with the development of a HRMIS. Additionally, in order to be able to forecast the required number of additional doctors, nurses and paramedics to be produced each year to attain desired levels, accurate baseline data is required. In view of this it is recommended that a full physical audit of all training institutions, including private and public and covering capacity, production, courses and faculty strength is urgently required. Study Area: Comprehensive audit of all training institutions in Punjab for key health personnel Gap Identified: Lack of reliable baseline data on capacity, courses, production and faculty strength of training institutions for key cadres in Punjab Key Objective: To obtain reliable data on all of the above in order to be able to plan and forecast human resource requirements

8. Study Area: Performance Management Gap identified: Lack of a unified, transparent Performance Management Mechanism for all cadres of nurses in Punjab Key Objectives:  

To determine whether the existing performance management activities were appropriately implemented An operations research to identify motivating factors among nursing workforce



To assess the possibility of introducing certain interventions can improve the productivity of nurses



To define scope and standards of practice for all cadres of nursing workforce



To define critical technical and behavioral competencies for different levels of nursing cadres



To study the job description and performance evaluation criteria established based on yardsticks driven from the job description of nurses in various cadres and on the competencies defined for various levels of nurse cadres



To develop performance evaluation forms and to assess performance on yardsticks derived from the individuals’ job descriptions.



To develop detailed forms and guidelines for the users



To conduct training on how to effectively manage performance

170

9. Study Area: CPD for nurses Gap identified: Lack of an institutionalised CPD programme for nurses in Punjab Objective: 

To assess the need for CPD programmes for nurses in various grades that can be linked to promotion



To study the current CPD programmes for nurses being offered nationally and internationally



To develop an institutionalised CPD programme for nurses in various grades linked to promotion

10. Study Area: Leadership development for senior leaders and mid-level nurse managers Gap identified: Lack of effective leadership among nurse professionals in Punjab Objective: 

To assess the key leadership behaviours based on organisational requirement and related to job description



To study the current leadership programmes that are being offered for nurses both nationally and internationally



To outline appropriate skills required from nurse leaders for effective representation at national and international level.



To enlist management tools to assist in the analysis of operational management factors which influence the efficacy of the managerial function in an institution

11. Study Area: Retention issues of Nurses due to lack of absorption plans Gap identified: Lack of absorption plan for nurses, LHVs and midwives in Punjab to reduce migration Objective: 

To assess the need for nurses, LHVs and midwives for effective healthcare service delivery in Punjab



To study the current output of nursing institutions in Punjab

171



To develop an absorption plan to improve the nurse population ratio and the nurse doctor ratio over the next 5 to 15 years



Provide, in close consultation and coordination with the Finance Department of Punjab the cost estimate for implementation of absorption plan

12. Study Area: Salary packages Gap identified: Lack of a competitive salary package for nurse professionals Objective: 

To assess the local competitive salary structures of nurse professionals



To study the current salary packages of other healthcare providers in the same BPS Scale



To investigate salary packages as being offered to nurse professionals in Middle East, UK and Canada



To develop an incentive package to meet the expectations of the competent nurse professionals

13. Study Area: Accreditation System Gap identified: Lack of an existing quality accreditation system for audit of nurse training institutions in Punjab Objective: 

To study the existing quality control mechanisms for nursing training institutions in Punjab



To investigate the quality accreditation system for audit of academic institutions available internationally



To propose a comprehensive quality accreditation system for audit of academic institutions after extensive stakeholder consultations

14. Study Area:

Advanced Midwifery Training Program

Gap identified: Lack of faculty and curriculum for advanced midwifery training i.e. Diploma in Advanced Midwifery Practices and Bachelors in Midwifery

172

Objective:    

To achieve the Millennium Development Goals 4 and 5 i.e. by improving maternal health and reducing child mortality through strengthening the Community Midwifery Practices. To assess the availability of trained midwifery tutors and their capability to teach advanced courses. To do a gap analysis between the curricula available to teach advanced midwifery courses and those approved by ICM. To develop a training program to upgrade the teaching abilities of the present faculty through three months residential training /crash course on basic core competencies to the present midwifery tutors or those who want to become midwifery tutors.

15. Study Area: Pre Service Training Program for Nurses, LHVs and Midwives Gap identified: Lack of Nursing Education Services Section in public sector hospitals in Punjab Objective: 

To assess the need for an effective Nursing Education Services section in public sector hospitals



To study the current nursing education programs that are being offered to new nurse appointees and transferees by the nursing section in the public sector hospitals.



To develop a comprehensive training program for new recruiters/transferees on nursing standard operating during the probationary period that is before confirmation of the contract.

16. Study Area: Workload assessment of healthcare facilities Gap identified: Optimal Utilization of available health human resource is lacking Objective: 

To assess the workload of healthcare facilities in terms of patient number



To study the quality, quantity and distribution of health human resource in Punjab



To develop a comprehensive plan to allocate the available health human resource as per the workload of the facilities for optimal utilization of available resources

173

Costing: Development of Human Resource Unit at DG Office

Staffing HR Director Deputy Director HRM Deputy Director HRM Deputy Director HRD Asst Director HR Management Officers HR Planning Officers

No. 1 1 1 1 3 2

Grade BPS 20 BPS 18 BPS 18 BPS 18 BPS 17 BPS 17

Unit Cost 0.445 0.315 0.315 0.315 0.246 0.246

Total (One Year) 5.34 3.78 3.78 3.78 8.85 5.90

BPS 17

0.246

5.90

HR Development Officer Computer Operators Asst HRM Officer Asst HRP Officer Asst HRD Officer Total

BPS 17

0.246

5.90

6 1 1 1 22

BPS 17 BPS 16 BPS 16 BPS 16

0.246 0.201 0.201 0.201 3.223

17.71 2.41 2.41 2.41 68.17

Costing: Development of Human Resource Unit at District Level

Staffing District HR Director

No. 1

Deputy Director HRM Deputy Director HRM Deputy Director HRD Asst Director HR Management Officers HR Planning Officers HR Development Officer Computer Operators Asst HRM Officer Asst HRP Officer Asst HRD Officer Total

1 1 1 3 2 2 2 6 1 1 1 22

Detail Computers Sets Furniture (desk/chair) HRMIS- design and architecture Total

Grade BPS 20/19 BPS 18 BPS 18 BPS 18 BPS 17 BPS 17 BPS 17 BPS 17 BPS 17 BPS 16 BPS 16 BPS 16

Number 44 44 1

Unit Cost 0.445

Total (One Year) 5.34

0.315 0.315 0.315 0.246 0.246 0.246 0.246 0.246 0.201 0.201 0.201 3.223

3.78 3.78 3.78 8.85 5.90 5.90 5.90 17.71 2.41 2.41 2.41 68.17

Unit Cost 0.085 0.013 8

Total Cost 3.74 0.57 8

8.098

12.31 (All figures in million Rs.)

1 3 6

per Tehsil per District per province

167

KEY RECOMMENDATIONS

To address the magnitude and complexity of the human resource issues currently facing the health department in Punjab the key recommended strategy is to establish and resource a fully functioning human resource department within the health system at provincial level with linked semi-autonomous units at district levels. It is further recommended that the newly established HR department should be reviewed after three years as is the normal practice in modern organisations. This exercise should be included in the annual planning process and budgeted accordingly. In order to progress the development of a dedicated HR Department within the medium term it is recommended that the simultaneous development of a comprehensive data base, HRMIS, would also be required. It is further recommended that an audit of the current human resource function is first undertaken to set benchmarks and scoping for the strategic development of the Human Resource Department. This will ensure that all aspects of human resource planning, management and development are included and all key HR functions provided for. Simultaneously it is recommended that staff should be recruited and trained in the human resource disciplines with separate sections established within the overall department to focus on the various aspects of human resource planning, management and development. As part of the development of a comprehensive human resource department it is recommended that further input is required to assess the needs and recommend more specific inputs to address the whole issue of people management. It is recommended that this should be undertaken from two perspectives, a) job roles and responsibilities in terms of line management and b) training needs for line managers to enable them to fulfil this crucial part of their responsibilities. Additionally linked to people management and job roles and responsibilities it is recommended that all job descriptions for those jobs having a people/line management responsibility be reviewed and strengthened in this aspect of the key responsibilities. Person specifications also need to be developed to support job descriptions. A comprehensive review of the current ACR framework is recommended if this is to be adapted for effective performance management. The recommended, preferred option would be to develop a completely new framework based on best practice and modern protocols for performance management. With reference to promotion of health staff it is recommended that a fully integrated promotion framework is developed. This would include the qualifications and minimum post graduate training and/or CPD hours required for each level of promotion. Service rules and regulations would also need to be revised accordingly. In order to be able to plan and forecast human resource requirements accurately a reliable baseline is required. This is already being recommended with the development of a HRMIS. In order to be able to forecast the required number of additional doctors, nurses and paramedics to be produced each year, to attain desired levels, accurate baseline data is required. In view of this it is recommended that a full physical audit of all training institutions, including private and public and covering capacity, production, courses and faculty strength

is urgently required. Possibilities for public private partnerships in this area should also be explored building on experiences gained for example with the Fatima Memorial System. To further assess the need of faculty strengthening it is recommended that a review of all facultiesâ&#x20AC;&#x2122; strengths be undertaken by an independent third party to assess the full situation and recommend further action. Minimum standards should be developed and implemented according to each institution. Standard levels of teacher student ratios should be set and similarly minimum qualification requirements for teaching staff. Incentives and increments in basic pay are recommended for the recognition and reward of post graduate qualifications and consistently good performance for faculty staff. It is strongly recommended that further attention be given to the development of a leadership programme for senior managers (leaders) i.e. EDOs, Programme Directors, hospital managers, senior nurses. Phased over a three year period all senior managers should undergo leadership development training as a requirement for professional and career development and a pre-requisite for promotion into higher senior positions. It is further recommended that management development programmes also be initiated and institutionalised for senior level managers i.e. unit heads of health facilities, Project Managers, as a pre-requisite for promotion to a senior manager post. Regarding the paramedics the key recommendation is that the re-structuring plan be rolledout without delay to meet the requirements for the MSDS and the recommended HR strategies. Similarly it is recommended that the MSDS protocols be rolled-out and implemented in accordance with the implementation plan. With reference to dual practice by health department staff it is suggested that a more extensive assessment of the situation would need to be undertaken in order to recommend protocols to influence this situation. It is recommended that a comprehensive study would be required to review, audit and make recommendations for both the private and informal sectors contributions to health care provision. The magnitude of these sectors warrants significant attention. Several areas of further study have been identified in this document and it is recommended that these be reviewed for further follow up.

LIST OF ANNEXES

Annex

Page

Annex 1. A complete list of key informants

Annex 2. Number of Sanctioned, Filled and Vacant posts of Doctors in different BPS (Grades)

Annex 3. A complete list of Medical & Dental Colleges in Punjab

Annex 4. Allocation of seats for first year MBBS 2008-2009 in Punjab

Annex 5 Number of Sanctioned, Filled and Vacant posts of Nurses in different BPS Scales

Annex 6: Summary of Key Human Resource Challenges

Annex 7: A Proposed Model for a Human Resource Department

Annex 8: A Proposed Organogram for a Human Resource Department

Annex 9: Faculty Strengths in Schools of Nursing

Annex 10: The main stages in good practice recruitment

Annex 11: Key elements required of a performance management system

Annex 12: Key requirements for a Promotion Strategy

Annex 13: The recruitment and promotion of Nurse from Grade 16 to Grade 20

Annex 14: Current Status of faculty strength in Schools of Nursing in Punjab

Annex 15: Presentation of International Consultant for the Consultative Workshop

Annex 16: Presentation of National Consultant for the Consultative Workshop

Annex 1. A COMPLETE LIST OF KEY INFORMANTS

(Arranged alphabetically) Mr. Abdullah Khan Sumbul Dr Abdur Rehman Khawaja Dr Abjad Toor Ahad Rashid Dr Akram Dr Altaf Hussain Dr Amir Ud Din Dr Amir ud Din Chohan Dr Amjad Amna Gulshad Ms. Amna Dr Anees Qureshi Arooj Naz Arshad Rashid Dr Arshad Usmani Mrs.Asfa Dastgir Dr Ashraf Chaudrey Mrs. Asia Shafiq Dr Aslam Chaudrey Dr Atiq-r-Khan Dr Attique Mst. Augistina Roy Dr Ayesha Nauman Dr Azim Jahangir Khan Mr. Basharat Ullah Mr.Basharat Ullah Dr Cheema Mr. David Wildman Farasat Iqbal Farrukh Pasha Dr Fauzia Ali Mst.Fazeelat Begum Mrs. Ghulam Narjis Ghulam Sakina Dr Haq Nawaz Bharwana Dr Haroon Ihsan Prof. Humayun Maqsood Hussain Jafri Dr Ijaz Munir Mrs. Irshad Javed

Mr. Jahanzeb Waheed Prof. Javaid Akram Lt. Col (Retd) Jawaid Iqbal Mrs. Kausar Parveen Kees Gruenedjh Mst. Khalida Jabeen Dr Khalique

Programme Director, PDSSP PSU, HRSP Director, DHDC, Sialkot DD, PDSSP Deputy Director SMO Programme Director PHDC Programme Director HSRP LHV, IRHC, Ghakkar LHV, RHC Ghakkar, Ghakkar Town, Gujranwala National Consultant Health Commission Student,Lady Aitchison Hospital Lahore DD, PDSSP Directorate General Health Services, LHV, PHNS, Lahore ComTech, Lahore BSc Faculty UHS & Saida Waheed FMH College of Nursing DGH DGHS Additional Director Admin. DCNS Lahore General hospital, Lahore Coordinator Midwifery Tutor Training Program Deputy Director HR, Fatima Memorial System EDOH,Div. Dir. Health services Senior Instructor Saida Waheed FMH College of Nursing BSc Faculty UHS & Saida Waheed FMH College of Nursing Ass. Prof. AIMC International Consultant MSDS PD, HSRP LHV Health Faisalabad Aga Khan University School of Nursing Nursing Instructor Lady Wellington Hospital, Lahore PHNS, Lahore LHV Trainer DHDC Chakwal Director, PHDC Advisor Academic Activities Saida Waheed FMH College of Nursing Principal FMH College of Medicine & Dentistry Coordinator Punjab Safe Motherhood Initiative DCO, Gujranwala Ex DG Nursing Director Nursing Education, Development and Clinical Services, Fatima Memorial Hospital, Vice President MAP PDSSP Project Officer Principal AIMC UHS, Dir Admin. & Coord. Principal College of Nursing AIMC Team Leader TAMA LHV Public Health Nursing School Lahore HMIS cell, DGHS

Dr M. Amjad Dr Majbadeen Prof. Malik Mubbashar Mr. Mansoor Ahmad Raja Mr. Mansoor Ahmad Saqib Ms. Misbah Zafar Dr Muhammad Muhammad Afzal Mrs. Munawar Sultana Dr Mushtaq Ahmed Salariya Dr Nadia Shar Dr Naeem Uddin Mian Prof. Naheed Sheikh Mst. Nargis Parveen Butt Mst. Narjis Dr Narwaz Bharwana Dr Nasir Shah Nasreen Akhtar Mst. Nasreen Butt Mr. Naveed Saleh Siddique Dr Nayab Ramzan Mst. Nazir Begum Nighat Yasmin Ms.Nisab Akhtar Dr Nisar Cheema Mr. Qurban Shah Mst. Rasheed Ayub Mst. Rasheed Majeed Ms. Rie Hiraoka Ms. Robina Kousar Rubab Zafar Mst. Rubina Jabeen S. Qurban Ali Sh Saadia Ilyas Dr Sabeeha Khursheed Dr Sabiha Ahmad Mst. Sajida Fursheed Mst. Shaheen Akhtar Dr Shahid Amin Mr. Shahid Javaid Mst. Shahida Nisar Mst. Shahida Parveen Mrs. Shahima Rehman Dr Shahzad Afzal

Dr Shakeel Ahmed Butt Dr Shakil Butt Dr Shakila Zamon Mst. Sharaf Sultana Prof. Shamim Ahmad Khan Mst. Shamila Shazia Younas Ms. Shenaz Kohsar Dr Simon Azariah

APD, HSRP LHW Coordinator, EDO health office, District Sialkot Vice Chancellor.,CEO, UHS Deputy Director M&E , HSRP, PMDGP Deputy Director (M&E) , Punjab Health Sector Reforms Program Programme Coordinator BScN, Saida Waheed FMH College of Nursing APD, PHSRP Senior Instructor Saida Waheed FMH College of Nursing DCNS Punjab Institute of Crdiology, Lahore Add Sec Technical WMO, RHC, Ghakkar ComTech, Lahore Prof. Community Medicine Director General Nursing Services LHV Public Health Nursing School Lahore Director PHDC Head of Family Medicine and Director CME Programme for GPs, at Fatima Memorial System LHV Chiniot Nursing Superintendent Lady Program Implementation WMO, RHC, Ahmad Nagar Principal SON Children Hospital, Lahore LHV, Public Health Nursing School President Pakistan Nursing Federation DHS Gujranwala PSU, PDSSP Controller Nursing Examination Board Assistant Director Nursing ADB representative Nursing Instructor LHV Health Faisalabad Nursing Instructor College of Nursing Lahore APO, PDSSP LHV, Health Provincial Programme Manager, MNCH Provincial Programme Coordinator National MNCH Prog DCNS Sir, Ganga Ram Hospital, Lahore Deputy Director General Nursing Deputy Director Medical Education Dir Finance and Budgeting, DGHS LHV , Nursing Instructor Children Hospital, Lahore Nursing Instructor College of Nursing Lahore Chairperson Executive Committee, Fatima Memorial System Executive Director Management & Development Health Specialist Consultant & CEO Standards and Accreditation Specialist DHO, Sialkot CIDA, SOHIP Dean, IPH Principal, DCNS Mayo Hospital, Lahore Ex Chief Executive Services Hospital, Professor of Surgery FMH College of Medicine & Dentistry LHV Public Health Nursing School Lahore Student, Lady Aitchison Hospital Lahore Community Midwife Project Director, SOHIP

Mst. Syeda Tasneem Syeda Tasneem Kausar Tabassum Shaheen Dr Tahir Amin Sulehria

Nursing Instructor College of Nursing Lahore Nursing Instructor PGN Lahore LHWS, BHU Badiana, District Sialkot MO, BHU Badian

Dr Tahir Manzoor Dr Tahir Suleiria Dr Talat Iqbal Dr Tanveer Ahmad Tariq Mahmood Dr Tasleem Akhtar Mrs. Tehmina Naureen Dr Umar Farooq Ms. Ure-Rehmana Quama Uzma Hussain Prof. Yasmin Rashid Prof. Zafar Ullah Khan Prof. Zafarullah Ch Dr Zahid Butt

Head of Health and Nutrition UNICEF MO, BHU, Badiana EDOH, Sialkot Program Manager National LHW Program APD PHSRP Advisor Research & Academic LHV, PHNS, Lahore Advancement LHV, BHU, Badiana, District Sialkot PSU, PDSSP KEMU,PMA Principal KEMU President CPSP MO, BHU Vario

Annex 2. NUMBER OF SANCTIONED, FILLED AND VACANT POSTS OF DOCTORS IN RHC & BHU

Vacancy Position Punjab RHC & BHU 2500

Filled Vacancies

2000

1201

1500

1231

1479

WMO (RHC)

1021

M O (RHC) SMO (RHC)

1000

500

198

222

110 127 223

175

198

190

255

270

267

224

230

240

242

Jun-06

Jun-07

Jun-08

Jun-09

218

MO/WMO (BHU) Non PRSP D S (RHC)

Years

Annex 3. A LIST OF MEDICAL AND DENTAL COLLEGES IN PUNJAB

Name King Edward Medical University Fatima Jinnah Medical College for Women Nishtar Medical College Quaid-e-Azam Medical College Punjab Medical College Rawalpindi Medical College Allama Iqbal Medical College Services Institute of Medical Sciences Sheikh Zayed Medical College

Location Lahore Lahore Multan Bahawalpur Faisalabad Rawalpindi Lahore Lahore Rahim Yar Khan

Annex 4. ALLOCATION OF SEATS FOR FIRST YEAR MBBS 2008-2009 IN PUNJAB

Category of Seats

KEMU

NMC

QMC

Open merit

262

229

Disabled Under developed districts

2 -

FATA AJK & NA Add. NA Foreign students technical assistance Foreign students self financed Reciprocal Balochistan Total reserved Grand total Category of Seats

RMC

SZMC

SIMS

AIMC

FJMC

Total

251

142

240

207

1909

2 18

249 251 Reserved 2 2 6 10

2 -

2 15

2 -

18 49

1 2 5

1 4 10

1 4 2 11

1 4 1 10

3 -

4 -

1 2 5

1 12 1 21

7 39 5 72

2 2 15 278 KEMU

3 2 42 273 NMC

2 5 35 285 QMC

2 5 35 288 PMC

2 2 23 275 RMC

22 100 SZMC

8 150 SIMS

2 2 15 257 AIMC

2 2 42 250 FJMC

15 20 237 2156 Total

Open merit

262

229

251

142

240

207

1909

Disabled Under developed districts FATA AJK & NA Add. NA Foreign students technical assistance Foreign students self financed Reciprocal Balochistan Total reserved Grand total

2 1 2 5

2 18 1 4 10

249 251 Reserved 2 2 6 10 1 1 4 4 2 1 11 10

2 1 4 1 10

2 15 3 -

2 4 -

2 1 2 5

2 1 12 1 21

18 49 7 39 5 72

2 2 15 278

3 2 42 273

2 5 35 285

2 5 35 288

2 2 23 275

22 100

8 150

2 2 15 257

2 2 42 250

15 20 237 2156

PMC

Annex 5. NUMBER OF SANCTIONED, FILLED AND VACANT POSTS OF NURSES IN DIFFERENT BPS SCALES

S.No 1 2 3

No of Sanctioned Posts Regular Contract 6239 3666 895 85 280 0

No of Filled Posts

Categories Scale Regular Staff/Charge Nurse 16 6239 Head Nurse, Deputy Nursing Suptt 17 564 Nursing Instructor, Asst Nursing 1 236 Instructor, Clinical Nursing Instructor, Nursing Instructor College of Nursing Asst Director Nursing, Principal 18 103 0 79 School of Nursing, Nursing Supretendant, Controller Nursing Examination Board, Nursing Instructor College of Nursing Principal School of Nursing, 19 22 0 13 Teaching Hospitals and DCNS, Deputy Director Nursing Director General Nursing, Chief 20 6 0 1 Nursing Supretendant, Principal Mayo Hospital Lahore (2), Principal Jinnah Hospital CON, Principal Services Hospital CON, Total 7545 3751 7132 *20 Male Nurses are working on Regular Contracts as Charge Nurses

No of Vacant Posts

Contract 1768 21 0

Regular 0 331 44

Contract 1898 64 0

1789

413

1962

Annex 6. SUMMARY OF KEY HUMAN RESOURCE CHALLENGES

SUMMARY OF KEY HUMAN RESOURCE CHALLENGES 

               

Lack of a comprehensive, dedicated, effective human resource department and framework in all disciplines and functions of HR i.e. planning, management, development Lack of reliable, quality HR data; difficulty of access to available data Lack of effective HR planning and forecasting Varied application of basic protocols for recruitment, promotion, contracting Lack of an effective performance management system; lack of accountability Shortfall in the absolute numbers of health care workers Imbalances in staff between the cadres Gender imbalance Vacant posts in rural areas High levels of absenteeism Frequent, unplanned, irrational transfers of staff Lack of transparent, effective mechanisms for career progression Absence of succession planning Staff dissatisfaction Lack of a dedicated, qualified management and administrative cadre Low levels of pay and remuneration packages No regulation of private and informal sectors

Annex 7. A PROPOSED MODEL FOR A HUMAN RESOURCE DEPARTMENT

Outline Guidelines for a Human Resource Department Model 1. The Human Resource Department will develop and roll-out HR policies and procedural guidelines in the form of a HR Manual to be made accessible to all staff within the health department which will be in compliance with all service rules and regulations and the MSDS; this will include all the key HR functions such as recruitment, induction, promotion, performance management, development and health and safety 2. The provincial HR department will gradually empower the district units to undertake all routine HR functions including recruitment; close coordination will be maintained; the district units will have autonomy in this regard 3. Regular updating and review of job descriptions will be undertaken by the provincial HR department with inputs from the district units; these will be supported by personal specifications for each role to be used during recruitment 4. The provincial HR department will, in close coordination with the district units, be responsible for overall HR planning within the health department for staff deployment at all levels; the district HR units would be required to develop updated annual HR plans based on a needs assessment 5. Allocation of health care staff would be based on the approved MSDS and restructured paramedics framework for primary and, secondary care facilities 6. The district HR units will have autonomy in terms of transfers and re-deployment within the district in accordance with approved protocols 7. The provincial HR department will retain authority for provincial and inter-district transfers and re-deployment. All transfers must be contingent upon actual need and be linked to performance 8. The provincial HR department will ensure adequate local production of required numbers of health human resources through the provincial training institutions, colleges and universities to meet the changing needs of the health care delivery system 9. Both the provincial and district units will be responsible for the development and follow up of HRD plans for in-service training and continuing professional development based on actual need for all staff within their jurisdiction; in the mid to long term personal development plans will be developed as part of the performance management process which will in turn form part of the HRD plan. The Provincial Health Development Centre and the District Health Development Centres will be strengthened and function as local training facilities 10. The HR development plans for in-service training will give priority in the short and medium term to developing and strengthening skills and capacities for MNCH, and MDGs targets 11. The HRD unit of the HR department will be responsible for developing and strengthening continuing education activities provided for all cadres of health workers at all levels; this to be in coordination with the accredited institutions and regulatory bodies 12. Promotion and career progression will increasingly over the mid-term be linked to performance and professional development and while the provincial HR department will continue to oversee significant continuing education programmes and post graduate training the districts will progressively take responsibility for in-service and short course learning events for all district based staff 9

13. The provincial HR department will retain responsibility and authority for the approval of all international training opportunities including participation in international seminars and study visits 14. The provincial HR department would be the key link with the medical colleges, nursing schools, paramedic and allied health professionals training institutions and all other such institutions in terms of curricula reviews and national standards, accreditation and regulations 15. The HR Planning section of the HR department at provincial level will be responsible for overall HR planning throughout the province supported by the district units who will also be responsible to develop district HR plans; both levels will ensure adequate HR capacity for all cadres across all programmes 16. Conducting and supporting research pertaining to human resources and applied health systems research and utilising the results for improving HR practice, including international best practice across the province, is a key function of the Provincial HR department and district units

Annex 8. A PROPOSED ORGANOGRAM FOR A HUMAN RESOURCE DEPARTMENT

H.R. DIRECTOR

D.D. HRM

D.D. HRP

D.D. HRD

HRM Senior officers (2)

HRP Senior Officers (2)

HRD Senior officers (2)

HRM OFFICERS (3)

HRP OFFICERS (3)

HRD OFFICERS (3)

COMPUTER OP. (2)

ASS. HRM OFFICER

ASS. HRP OFFICER

ASS. HRD OFFICER

Annex 9. FACULTY STRENGTH IN SCHOOLS OF NURSING (TEACHING HOSPITALS) IN PUNJAB

Sr.No.

Name of School of Nursing

Bed strength

Present Student Strength

Faculty

SON Mayo Hosp, Lahore 2. SON Services Hosp, Lahore 3. SON SGRH, Lahore 4. SON ** LGH, Lahore 5. SON** Jinnah Hosp, Lahore 6. SON ** Children Hosp, Lahore 7. SON S.Z.Hosp, R.Y.Khan 8. SON Allied Hosp, Faisalabad 9. SON** Nishter Hospital, Multan 10. SON**BV.Hosp, Bahawalpur

1883

1799

General Nursing 250

1981

1198

110

1948

610

158

1962

612

121

1999

1100

260

1994

320

300

1975

641

1990

1100

300

1953

1103

150

1952

1449

130

11. SON Holy Family Hospital, Rawalpindi 12. SON R.G.H, Rawalpindi 13. SON * LWH, Lahore 14. SON * LAH, Lahore 15. DHQ Hospital, Sheikhupura 16. DHQ Hospital, Okara 17. DHQ Hospital, Kasur 18. DHQ Hospital, Gujranwala 19. Allama Iqbal Memorial Hospital, Sialkot 20. DHQ Hospital, Narowal 21. DHQ Hospital, Hafizabad 22. Aziz Bhatti Shaheed Hospital,Gujrat 23. DHQ Hospital, M.B.Din 24. DHQ Hospital, Rawalpindi

1978

864

120

1980

680

204

1965

228

100*

1981

387

1997

125*

1997

197*

1983

405

1984

297

2002

48*

1999

90*

2000

322

1997

60*

400

Date of Establishment

Nurse Midwife 60

C. Midwife --

25. DHQ Hospital, Jhelum 26. DHQ Hospital, Attock 27. DHQ Hospital, Chakwal 28. DHQ Hospital, Sargodha 29. DHQ Hospital, Mianwali 30. DHQ Hospital, Khushab 31. DHQ Hospital, Bhakkar 32. DHQ Hospital, Faisalabad 33. DHQ Hospital, Jhang 34. DHQ Hospital, T.T.Singh 35. Eye Cum General THQ Hospital. Gojra 36. DHQ Hospital, Lodhran 37. DHQ Hospital, Khanewal 38. DHQ Hospital, Vehari 39. DHQ Hospital, Pakpattan 40. DHQ Hospital, Sahiwal 41. DHQ Hospital, D.G.Khan 42. DHQ Hospital, Rajanpur 43. DHQ Hospital, Muzaffargarh 44. DHQ** Hospital, Layyah 45. DHQ Hospital, Bahawalnagar Total:

* **

1974

355

1997

161*

1997

125*

1996

450

1998

200

1997

125*

1999

151*

1990

600

1997

353

1997

125*

1997

205

1997

100*

1997

125*

1997

125*

1997

60*

1997

388

1997

500

Nil

1997

236

1997

167*

1997

120*

1997

244

17961

4576

1336

1251

269

184

PNC Criteria for School of Nursing Attached with hospital need 200 beds strength. Nursing Instructor having Post RN Degree. Source: DGN Office dated: 17/11/2007

Annex 10. THE MAIN STAGES IN GOOD PRACTICE RECRUITMENT

Stages of Recruitment

Job Analysis

Job Description

Person Specifications

Attract and Manage Applications

Shortlisting and Selection

Make the Appointment

Induction

Annex 11 . KEY ELEMENTS OF A PERFORMANCE MANAGEMENT SYSTEM

Key Elements to include in Performance Management 

           

a simple, user-friendly annual review format that is based on the objective review of key performance indicators in relation to the job description, roles and responsibilities; one section to be completed by the line manager and one section to be completed by the staff member the line manager must be in a position to independently assess the staff member in all aspects of the performance management protocol; if not the previous line manager would contribute to the review process performance improvement protocols built into the process awareness of the line manager of the consequences of the review outcome i.e. may affect promotion prospects negatively or conversely support promotion of a poor performer options for development; a Learning and Development plan for the individual should be developed and form part of the performance review process management of performance and behaviour to ensure that staff are being encouraged and supported to behave in a way that allows and fosters good working relationships, team approaches and mutual respect the review record must include space to record key points of discussion during the review session by both parties; space must be provided for staff comments with reference to the line manager the document must be signed in hard copy by both parties and the HR department upon completion and filed in the personal file of the staff member for future reference new objectives, KPIs, must be set for the year ahead and agreed by both parties performance management is the basis for promotion or demotion in the case of unsatisfactory performance a further review date, within six months maximum, must be set and agreed with key objectives set for that specific timeframe additionally key competencies may be set in accordance with the person specifications for the post and also mutually reviewed adjustments may be made to the job description as a result of this annual review and jointly agreed by both parties

Annex 12. KEY REQUIREMENTS FOR A PROMOTION STRATEGY

Key Requirements for a Promotion Strategy        



A precise list of required qualifications, skills and experience for the post A person specification requirement A job description for the post A sound, comprehensive employee performance management system in place; this may include a performance bar i.e. if a person is consistently performing at 80% or above h/she may be considered for promotion A communication protocol for announcing promotion opportunities within the organisation An application protocol; this should be through the hr department and a timeframe for applications set An induction or training plan for the newly promoted person to further enhance their potential A transparent selection process or review protocol based on evaluation of each potential promotee on how well they meet the set criteria i.e. comparison of the candidates skills and competencies to the pre-determined requirements for the post and the performance history Clear documentation of protocols for the process and decisions taken

Annex 13. THE RECRUITMENT AND PROMOTION FROM GRADE 16 TO GRADE 20

S.No