As harsh as it may sound it is a fact that a large number of nurses in Pakistan are, by and large, neither skilled nor trained. Only a small number of nursing students receive proper education and structured training in their schools and training hospitals. Very few of the 162 nursing schools in Pakistan have a properly trained faculty to teach theory in classes, or clinical teachers to train nursing students in the outpatient department (OPD), and wards and other important areas of the hospital.

A majority of nursing schools are facing shortage of human resources because of unavailability of funds and lack of interest by authorities at the federal and provincial levels. Many nursing schools are established in rented buildings and are not attached to any hospital and students are awarded a diploma in nursing after completing their so-called ‘course work’. The nurses also often face sexual harassment and are exploited by doctors, male paramedics, hospital administrators and owners, patients and their attendants. It is sad that in majority of the cases it is the nurses who are blamed for the acts of omissions and commission by others in the system.

In 1935, before Partition, a training programme for nurses was started at Civil Hospital Karachi, which was followed by similar programmes at Lady Reading Hospital Peshawar and Mayo Hospital Lahore. The Pakistan Nursing Council (PNC) was established in 1948 and the Nursing Council Act was passed in 1952, which was amended in 1973 after East Pakistan became Bangladesh and the four provinces of West Pakistan were restored.

The PNC was supposed to be an autonomous and independent body regulating nursing education and training in Pakistan by helping provincial nursing examination boards and the armed forces nursing services. Because of lack of interest shown by different federal and provincial governments amid powerful interest groups, the PNC has not been able to function independently. In spite of this, the PNC is trying to do its best to improve the state of nursing and midwifery in the country. But it is very difficult for an organisation to work as per its mandate without the support of government and other key stakeholders.

An interesting phenomenon that can be seen in Pakistan is that doctors have also served as members of national and provincial assemblies — of which some became ministers, while some held higher offices such as that of speaker, chief minister and governor. In electronic media — which is arguably as powerful as politics — we have doctors working as anchors and hosts on national television.

Despite this, it can be as said that neither the legislators nor public opinion-makers have contributed anything substantive for the betterment of medical education and training in Pakistan. In fact, the National Assembly and the Senate passed the 18th Amendment Bill in haste and without necessary deliberations. This resulted in making the federal level institutions such as the Pakistan Medical and Dental Council and the Pakistan Nursing Council ineffective. They did not understand that without adequate proper planning capacity at the provincial level it is not possible to design and deliver quality healthcare for the poor people of Pakistan.

Nurses are the backbone of a healthcare system. But in Pakistan, they are poorly trained, underpaid and not valued as professionals

According to the latest official statistics there are 40,879 nurses and 12,488 doctors in Sri Lanka; 154,309 nurses and 66,880 doctors in Iran; while in the USA there are 3.3 million nurses and 730,811 doctors. But in Pakistan it is the other way around: 94,766 nurses and 184,711 doctors. And the irony, as mentioned earlier, is that the majority of these nurses are not well-trained which renders our healthcare system weak. This doctor-nurse ratio also shows how serious our policymakers are about the health of the nation. Our parliament hardly knows about these alarming statistics and the anchors on various TV channels do not even understand the significance of this shortfall. 

The Pakistan Medical Association has been demanding that we need an army of paramedics including general nurses, midwives and specialised nurses to run our basic heath units, rural health centres, taluka and district general hospitals to provide primary healthcare to all citizens. A country cannot provide healthcare to its people without competent healthcare workers, of which skilled nurses play an integral role.

In countries like China, Iran and Indonesia, a dedicated cadre of community nurses help in providing preventive medicine to eradicate polio, malaria and waterborne diseases. It is so depressing to see that the chief minister of the biggest province of the country with unlimited resources has to sit with health officials every year to announce his war against dengue fever. I wish he had invested that amount to strengthen the nursing profession in his province, which would have helped in the long term.

It is a very sad situation that in the last 70 years of our independence we failed to produce a single nursing textbook in Urdu and regional languages. A majority of students in our nursing schools are using the notes of their seniors in Urdu in the absence of a proper textbook. It is not possible for many students to read and understand nursing textbooks in English. When I was taking a class of first year students in a nursing school a few years ago in Karachi almost every student told me that they had cleared their matriculation examination by naqal and not by aqal.

With this kind of education system, it is very difficult to train nurses properly. To overcome this basic education gap, we have designed a special three-month extensive course where Urdu, English, geography, history, basic mathematics and conservation of environment is taught. It has been observed that a majority of young students are very keen to learn if an enabling environment is provided to them.

The majority of public nursing schools in the country are victims of negligence, chronic shortage of resources and competent faculty.

The nursing profession in Pakistan is very unattractive for anyone to adopt as a career. There is no career structure for them, and they are nominally paid. There is no organised system to impart training in nursing and midwifery schools all over the country. There is no performance audit system to identify areas of improvement. Despite the efforts of the PNC, Pakistan Nursing Federation and the Pakistan Midwifery Association, health planners in the country are not ready to develop this profession as should be done in the interest of patients and the poor.

There are 40,879 nurses and 12,488 doctors in Sri Lanka; 154,309 nurses and 66,880 doctors in Iran; while in the USA there are 3.3 million nurses and 730,811 doctors. But in Pakistan it is the other way around: 94,766 nurses and 184,711 doctors.

Many missionary hospitals like Christian Missionary Hospital in Sialkot, Mission Hospital in Quetta, the Seventh Day Adventist and Holy Family hospitals in Karachi are providing good education and training. The same is true for the excellent training programmes offered at the Aga Khan University Hospital (akuh) and Armed Forces Nursing Schools. All of them have developed systems and procedures to select good students, and they have well-paid and qualified faculty members with post-graduation education and training in nursing and teaching. The nursing students are provided quality training and, on their graduation, they are offered well-paid jobs in their network.

In the military, nurses serve with honour and dignity and have the opportunity to strive to reach to the highest possible ranks. A majority of the skilled nurses trained in missionary and private hospitals like the AKUH leave the country to work abroad as it is very easy for a competent nurse to get a well-paid job overseas.

Our health planners in the federal and provincial governments should understand that healthcare is not about production of thousands of glorified doctors — healthcare cannot be provided in buildings without sheets on hospital beds, and basic facilities like water, toilets and basic instruments. It is definitely not possible just by buying very expensive equipment like CT scanners, MRI machines and robotic surgical system.

It is also impossible to provide healthcare to the masses by announcing million-dollar projects in different parts of the country and forgetting about it when the helicopter leaves town. An efficient healthcare system can only exist when nurses are well-trained, well-paid, and work with passion and humility. It is only possible when the nurses are valued as professionals and made partners in taking care of patients in hospitals and community. It is time that plans are made for their continuous medical education and development of different specialties of nursing.

We need a powerful, autonomous and independent PNC with resources to rectify the problems in nursing education and training system in Pakistan. We need a task force to translate resource material for nursing education in Urdu and other national languages like it has been done in Iran, Indonesia and Turkey. We should establish a respectable carrier structure for nurses and empower them to provide primary and basic healthcare to people of Pakistan. We should have a system of audit and accountability to monitor nursing education and training. We should also have a strong professional body to protect nurses and fight for their rights with the help of civil society.

If we are really interested in helping the masses and looking after their health, then we must set our priorities. A healthcare system can be functional without doctors but it cannot deliver without nurses.

The writer is the ex-secretary general of the Pakistan Medical Association

Published in Dawn, Sunday Magazine September 25th, 2016