1. Khowaja, Khurshid PhD, RN, RM, PDF

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Health-seeking behaviors and determinants of the use of health services, especially in the context of developing countries such as Pakistan, is an important concern. In Pakistan, 3.1% of the gross domestic product is spent on economic, social, and community services; 43% is spent on debt servicing.1 About 0.8% is spent on healthcare, which is lower than in Bangladesh (1.2%) and Sri Lanka (1.4%).2 In 2005 and 2006, less than 17$ was spent on each Pakistani's health, which is very low based on international standards.3 However, improvements in the last 30 years4 include doubling the childhood immunization rate and increasing family planning knowledge.


The Healthcare System

The healthcare system in Pakistan has both public and private health facilities. Healthcare workers include 91,823 physicians, 37,623 nurses, 4,175 dentists, 22,528 paramedics, and 5,619 female health workers. There are 796 hospitals, 93,907 hospital beds, 5,171 basic health units, 531 rural health centers, and 856 maternity and child health centers.4-6 Basic-level healthcare dispensaries (n = 4,635) offer primary healthcare5-7; however, they have restricted hours of operation and are often located distant from the population. The private sector has not only some accredited outlets and hospitals but also many unregulated hospitals, medical general practitioners, homeopaths, hakeems (Muslim physicians), traditional/spiritual healers, Unani (Greco-Arabic) healers, herbalists, bonesetters, and quacks. Nongovernmental organizations are also active in the health and social sector.8


Many factors contribute to poor utilization of primary healthcare services, including low socioeconomic status, lack of physical accessibility, cultural beliefs and perceptions, low literacy level of mothers, and large family size.2-5,7 Poverty, coupled with illiteracy, the low status of women, and inadequate water and sanitation facilities, has a deep impact on health indicators.4 Besides limited knowledge of illness and wellness, cultural prescriptions,9 perceptions of a health services, providers, social barriers, and cost are major barriers to providing effective health services.10 This affects the physical and financial accessibility of health services.


The Pakistani healthcare system is neither competent nor comprehensive to provide adequate services for the growing population.6 Lack of access to health services, deficient health infrastructure, extreme poverty, and lack of awareness among the population regarding health maintenance are fundamental barriers to public health advancement. Healthcare problems include inadequate resources, inefficient and ineffective use of those resources, uneven quality of services, inadequate and inequitable distribution of government allocations to hospitals and hospital personnel, minimal attention of government physicians to public service, and lack of established and comprehensive health services research programs.11 Although the government provides free healthcare to its citizens, no mechanism exists in the government, private, or semiprivate healthcare sectors to monitor clinical quality according to international standards. This means that the people of Pakistan are deprived of their basic human right to access good healthcare.


Health Problems

Healthcare problems are directly linked to the prevailing social, economic, and political systems that determine the allocation of resources in and outside the health sector. The health indicators of Pakistan are the following: life expectancy, 61 years; crude death rate, 8 of 1,000; crude birth rate, 35 of 1,000; mortality rate of persons younger than 5 years, 120 of 1,000; infant mortality rate, 91 of 1,000; and natural rate of growth, 3% per annum.12 According to a study on the burden of disease, diarrhea, lower respiratory infections, ischemic heart disease, septicemia, and injuries are among the top 15 causes of premature deaths.13 Nearly 10% of Pakistan's 155 million population carries the deadly hepatitis virus. In addition, the country recently faced additional public health threats that include cholera outbreaks after a 7.6-magnitude earthquake in 2005, dengue fever, and outbreaks of bird flu. Key public health problems include heart disease, respiratory infections, and waterborne parasitic diseases.14 Poor nutritional status is the major health problem of many. Of every 3 children, 1 is malnourished, and about 8% of those younger than 5 years are anemic. Of 7 older adults, 1 is obese or overweight, 1 in 3 is underweight or severely thin, and adult women are more anemic than men.15


Chronic diseases common among Pakistani people include hypertension (1/3 persons >45 years) and type 2 diabetes (1/10 women). Chronic bronchitis affects 1 of 10 rural women older than 65 years, and 5% of men older than 60 years have signs of renal impairment. Within 6 months of delivery, about 52% of women have tetanus. Similarly, drug abuse has emerged as a public health problem, whereas malaria and tuberculosis continue to be major threats.6 About 25% of children are in only fair or poor health. Children younger than 5 years have, on average, 6 episodes of cough with fever in a year and between 5 and 12 episodes of diarrhea annually.6 Disabilities are another important health concern. Among people older than 65 years, hearing impairment is common, about 15% are blind, and more than 65% have cataracts.6


Nursing Profession

Although nurses are still in the early stage of gaining respect and professionalism, the poor public image of nursing in male-dominated Pakistan has not changed. There is a severe nursing shortage, with only 46,331 registered nurses for a population of 150 million.16 With a nurse-to-physician ratio of 1:2.66, there is 1 nurse for every 2,973 people and 1 physician for every 1,287 people.8,11 This issue has worsened because of nurse immigration to other countries.


Administrators and faculty in nursing schools have major challenges: availability of qualified faculty, classrooms, required course syllabus, physical environment, and availability of teaching aids. Senior nurses act as tutors in some subjects. Until recently, nursing education in Pakistan was largely ignored because of the lack of available trained faculty.6 Fourteen nursing degree programs have 97 faculty members and an annual enrollment of 711 students. Over the next 5 years, the annual enrollment is expected to rise to 1,200. To meet these needs, an additional 291 nursing faculty will be required, including 20 professors/associate professors with PhD degrees and 250 assistant professors with at least master's degrees in nursing.


Nursing Practice

Faculty shortages do not allow students to acquire required clinical expertise. However, there is no published quantitative data on the impact of nursing knowledge and practice on patient health-related outcomes or the gap in nursing competencies at the entry level in practice. In many countries, nurses are recognized as direct care provider professionals, with an important role in maximizing the quality of the delivery of patient care, whereas in Pakistani hospitals, nurses still rely on physician assessment and orders without conducting their own patient baseline assessments, setting the patient's healthcare-related goals, and implementing individualized plans of care.


I am the first national director of nursing services at the Aga Khan University (AKU) Hospital ( My many challenges and stresses, like those of most women leaders in third-world countries, are the main part of my life as I live in a male- and physician-oriented society. However, in comparison to my nursing colleagues in other hospitals, I am fortunate to have better clinical expertise, wages, empowerment, and leadership potential to promote maximum nursing respect and a voice for nurses. My work includes shaping and directing nursing policies/procedures/protocols; being a facilitator and advisor for nursing practice in inpatient, ambulatory, off-campus, and home health programs, patient care management, staffing plans and management, and staff development, in particular, unit-based competencies; and facilitating new openings and current expansion of facilities, equipment selection, purchase and maintenance, staffing, physical layout, and operational management plans. I work to enhance the image of nursing and guide the nursing division into becoming an integral part of AKU. I am also a facilitator and advisor for nursing practice in other countries such as Syria, Afghanistan, Egypt, and East Africa, as well as for nursing quality assurance programs in 17 Karachi hospitals. I also assist AKU ( faculty in the master's degree program, research publication, and many other roles.


Although it is exciting to be in challenging leadership roles in Pakistan, nurses are always alone as their own nursing colleagues do not appreciate and market nursing leaders' capabilities wherever required. However, I have never lost hope and have always acquired the best knowledge and expertise to face challenges, and, inshallah (if Allah wills), by the end of February 2009, I will be the first international fellow nurse of McMaster University, Canada.



Moving the nursing profession into the mainstream of healthcare delivery in Pakistan requires great effort on many fronts. There is a great need to change the public image of nursing among the Pakistani population so that the profession is more respected by patients and their families, as well as by professional colleagues, such as physicians, pharmacists, dietitians, and physiotherapists. Nurses need to move toward multidisciplinary approaches and replace their traditional delivery of care with collaborative models. Given nurses' important role, it is a great challenge for nursing to retain its uniqueness while embracing a true multidisciplinary plan of care. To promote nursing higher education in the country, comprehensive efforts are needed to implement a comprehensive faculty development program.


Nurses have the unique and wonderful opportunity to make a difference in the lives of many people. Nurses are also privileged to be able to learn and grow personally from the courage, self-will, and incredible spirit that patients display during every day of their illness and healing journey. The diverse roles of the nurse suggest that although technical and clinical skills are very important, they must be accompanied by human supportive skills. As nurses, we need to embrace our humanness and learn to truly be with our patients, to take the time to get to know them, and to discover what has importance and meaning for them as they describe their experiences to us. Progress will occur as nurses actively participate in the development and implementation of quality initiatives and innovations in healthcare.



The key to a successful healthcare system in Pakistan lies in top management leadership support and commitment; continued clinician support and acceptance; a dedicated team of nurses, physicians, and paramedical professionals; and strong financial methods for improving consumer information, making services or products more affordable through some form of subsidy and creating alternatives for the consumer to access services at a lower cost.




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