Perceived myopic approach

August 2, 2008 -- Today The News (Pakistan) published a report by Imtiaz Ali headlined "Acute shortage of nurses and midwives resulting in casualties." The report, which appears to be based on recent books, describes the "terrible" state of nursing in Pakistan, which includes inadequate training resources, an atmosphere of social disrespect, and an astonishing lack of nurses. Reportedly, the nation has one nurse for every eight physicians, when adequate care requires far more nurses than physicians. The report is not free of physician-centric assumptions, but on the whole it provides a valuable look at a very sad state of affairs.

The report begins with sobering statistics, apparently annual data about Pakistan, drawn from Dr. Sher Shah Syed's "Best Ways of Training for Nursing and Midwifery" and Syed and Tazeen Saeed Ali's "Practical Ways of Training for Nurses." The report does not say if the book authors are nurses, and some readers might conclude (rightly or wrongly) that they are physicians. According to the news report, 400,000 infants die within their first year, and 30,000 women die from pregancy-related complications. The report says that 80% of deliveries occur at home "by trained or untrained birth attendants."

The piece links the mortality data to a lack of well-trained nurses and midwives. It notes that there is only one nurse for every eight physicians, even though "prescribed standards" say "there should be 15 nurses for assisting a single doctor." Of course, nurses do work with physicians, but their care is not defined by "assisting" them, and the majority of nursing is not directly related to physician care. In addition, the basis of the 1:15 ratio is not clear; few if any nations approach that ratio, unless the report is defining "nurses" to include a very broad range of other personnel. At the same time, the report notes, 12,000 of the physicians have no jobs.

The report says the books offer several reasons for the poor conditions. These include "that the colonial rulers introduced a curative based health delivery system"--the report might have explained that more, perhaps linking it to the relative surplus of physicians--as well as that the health infrastructure had decayed due to poor policies and power struggles among different levels of government, and the lack of trained staff, "especially nurses and paramedical staff." Apparently there are no nurse training courses available in Urdu and other languages, and programs that do exist suffer from a shortage of trained faculty.

The article links the problems for nurses and midwives directly to the attitudes of decision makers and society. It suggests that policy makers "are not serious" about training (at one point it describes their "perceived myopic approach") and that they "do not realise that the health system cannot function properly without competent and professional nurses and paramedical staff." At another point, the piece explains that "nursing is not considered a proper profession by the family and community members." The report says most Pakistani nurses now "belong to under privileged families." According to the article, the book writers stress that if nurses and midwives receive "due respect" and adequate salaries and benefits, the health of mothers and children "can improve."

The report's focus on social views as a root cause of the nursing crisis is right on target. Too many reports about the nursing shortage recite statistics without considering the deeper reasons such conditions develop and persist. Until decision makers at all levels get a better sense that nurses are critical to patient outcomes--partly through reports like this one--the situation is unlikely to improve much. We commend Imtiaz Ali and The News.

See the article "Acute shortage of nurses and midwives resulting in casualties" by Imtiaz Ali in the August 2, 2008 edition of The News.